Help with Board Question ( No Word Count), Unit Assessment (Note Word Count). APA Format Throughout to include Reference Page. 

Board Question

For an accident investigation, what is more important—an eye witness or a mountain of physical evidence? Explain your choice.

Unit Assessment

QUESTION 1

There are several interviewing tips; which, in your opinion, is the most important? 
Your response must be at least 75 words in length.

QUESTION 2

Why is a “ready” investigative kit so important and valuable to accident preparedness? 
Your response must be at least 75 words in length.

QUESTION 3

One step in the accident investigation process is preserving the scene of the accident. How do you preserve an accident scene? 
Your response must be at least 75 words in length.

QUESTION 4

Consider the following accident scenario: 
Three workers were assigned to replace a water valve located in an underground concrete vault. After removing the manhole cover, worker #1 climbed down the ladder into the vault. Worker #1 collapsed and became unconscious within seconds of reaching the bottom. Worker #2 went down the ladder to rescue worker #1 but was quickly overcome by the lack of oxygen. Both workers died at the bottom of the vault. Worker #3 stayed outside the vault and called for emergency response after worker #2 collapsed. 
Develop a list of five questions you would ask a witness to the accident. Explain why you chose each question. 
Your response must be at least 200 words in length.

QUESTION 5

Consider the following accident scenario: 
Two workers were assigned to replace a water valve located in an underground concrete vault. After removing the manhole cover, worker #1 climbed down the ladder into the vault. Worker #1 collapsed and became unconscious within seconds of reaching the bottom. Worker #2 went down the ladder to rescue worker #1 but was quickly overcome by the lack of oxygen. Both workers died at the bottom of the vault. Worker #3 stayed outside the vault and called for emergency response after worker #2 collapsed. 
Applying the “four P” evidence concept (physical, paper, people, and photographic), discuss the evidence related to the accident that you would want to collect. Explain the reasons for your choices. 
Your response must be at least 500 words in length.

Employee Relations Law Journal 3 Vol. 37, No. 3, Winter 2011

Safety, Accidents, and Investigations:
Be Prepared for the Unexpected

Robert A. Battles

This article describes how to establish and maintain an accident prevention plan,
respond to accidents in the workplace, and handle potential external investigations.

A s the economy moves forward in a slow recovery, employers vigilantly watch for new opportunities to cut costs. One sure way
to reduce costs is to have a strong safety and health program (safety
program). If you fail to have a strong safety program, you are exposing
your company to potential increases in health care costs, penalties and
fines, and lost productivity. Covering the basics in this area will protect
your company and its employees.

Every employer that does work in the United States is subject to the
safety and health laws issued by the Occupational Safety and Health
Administration (OSHA) or the equivalent state programs. State programs
must meet or exceed the requirements set forth by OSHA. Even if a
company has only one employee, it must have an established safety
program.

In order to have an effective safety program, you must have a writ-
ten, active Accident Prevention Plan (plan), be prepared to respond to
accidents effectively, and strategically handle external accident investi-
gations.

DEVELOPING YOUR ACCIDENT PREVENTION PLAN

The accident prevention plan is the core of any safety program. It
will defi ne potential safety issues in the workplace and outline how to
reduce or eliminate those issues. It will guide you in implementing your
safety program by including steps to act quickly and decisively should
there be an accident, and it will offer steps on how to manage accident
investigations and how to recognize when you need to seek profes-
sional advice.

Developing the plan allows employers and employees to work
together on preventing safety and health hazards.

Robert A. Battles is counsel to the fi rm at Lane Powell PC where he
represents clients in regulatory and litigation matters, including occupa-
tional safety and health investigations and defense. He can be reached
at battlesr@lanepowell.com.

Safety, Accidents, and Investigations

Vol. 37, No. 3, Winter 2011 4 Employee Relations Law Journal

Step 1: Developing the Basic Accident Prevention plan

Every company must assess its own worksite(s) for known and poten-
tial hazards. This allows the plan to be customized for each worksite,
more accurately refl ecting company safety issues. In addition, compa-
nies must periodically review their plan to ensure it refl ects ongoing site
needs. A generic, unchanging plan is not enough.

There are many elements of a basic plan. Development of the initial
plan may feel overwhelming, but it will pay off in the end. If you assess
each of these elements in order, step-by-step, you will develop a plan
that allows you to be in compliance. The basic plan includes:

• An overview of the company’s safety program;

• What to do in an emergency;

• The location of fi rst aid kits;

• How to report injuries;

• How to report unsafe conditions;

• How to identify hazards in the work environment;

• Employee safety orientation (when a new employee is hired
and when a job changes); and

• Safety meetings or a safety committee (depending on the com-
pany size).

Development of the plan is a team effort. The plan must include
employees’ involvement from every level of the organization. This
allows for a more comprehensive review of work practices. When all
levels of employees are involved, there is a better understanding of the
safety issues related to their job and they are invested in establishing
safe practices. Thus, the plan becomes more effective in practice.

Step 2: Job Hazard Analysis

Once you have met the requirements above, you must assess the
work that employees are performing through a job hazard analysis,
which is a survey of the tasks where injuries occur or could occur.

To conduct this analysis, fi rst identify the possible ways an employee
might become injured doing a particular job. Then, note possible
causes of such potential injuries. Once you know the possible injuries
and their root causes, you can more effectively address solutions or
preventative measures. All of this information must be included in the
written plan.

Safety, Accidents, and Investigations

Employee Relations Law Journal 5 Vol. 37, No. 3, Winter 2011

As an example, a particular job might require heavy lifting, which
could cause injuries. Causes of those injuries might be from trying to lift
items that are too heavy or are awkward in size, or from using inappro-
priate lifting techniques. As a result of a company’s job hazard analysis,
an employer may choose to include weight limits for individuals respon-
sible for lifting items and provide training on proper lifting techniques.

It is advisable to conduct part of the analysis on the actual jobsite
while the employee is in the course of his or her duties. This can
help you notice less obvious safety considerations. For example, if an
employee has an offi ce job, one might think there are no pertinent
safety issues. However, on further observation, one might note repetitive
work, such as typing and using a date stamp, or physical lifting, such
as sorting fi le boxes.

Below are examples of work duties that must be addressed in the
written plan, should they be discovered in a job hazard analysis:

• Activities requiring personal protective equipment;

• Ladder use;

• Walking or working on surfaces more than four feet in elevation;

• Operation of machinery;

• Use of powered hand tools;

• Automobile or truck operation on public roads;

• Industrial vehicle operation ( i.e ., forklifts, etc.);

• Use of chemicals, or proximity to chemicals; and

• High volume of repetitive work.

When developing a plan, the employer must tailor it to the specifi c
safety needs of each position. Avoid being overly general, such as say-
ing that employees must “be careful,” when they really need detailed
procedures to be safe. On the other hand, do not be so specifi c as to
remove the employee’s responsibility of using common sense.

Step 3: Training

Even the best plan is not effective when it is only on paper. Employers
must still train their employees on safety requirements. This includes
job-specifi c training for each and every employee and manager. Training
must be done when an employee is hired or changes job duties and
whenever the plan is updated or modifi ed. Any training provided should
be documented in writing. Ensure that your company’s plan outlines the

Safety, Accidents, and Investigations

training requirements for each type of position. Then implement steps to
make sure your employees stay current on their training.

Step 4: Ongoing Review

Once the plan has been implemented, the company must regu-
larly review it to ensure relevancy and effectiveness. The type of
review process can vary, depending on what is outlined in the plan.
At the very least, the plan should include annual audits, review
of audit findings, implementation of audit findings, and accident
investigations. The plan should be reviewed at least annually to
determine if it is accurately reflecting the current safety needs of
the company.

The annual audit will be very similar to the development of the initial
plan. While not as extensive, it should be thorough enough to confi rm
the plan continues to meet the safety and health needs of both the
employer and employees. Review of the plan should include looking
at safety measures and goals expressed in the initial plan, and should,
like the original plan, involve all levels of employees. Once the audit is
completed, it is critical that any fi ndings be reviewed and appropriately
implemented. This includes retraining all employees affected by changes
made to the plan.

Every accident should be recorded on an OSHA Form 300 and inves-
tigated as to its cause and future preventability. Any fi ndings from such
investigations should be used to update your plan.

BE PREPARED TO RESPOND TO ACCIDENTS EFFECTIVELY

Accidents can happen, even with a plan in place. While most inci-
dents are easily addressed, you must prepare for an unexpected event.
Employees will look to management for guidance on how to act and
move forward.

Being prepared allows you to immediately put the emergency plan
into action, confi dently addressing the needs of all who are impacted
and avoiding missing key elements. If you are prepared in advance, you
will be able to weather any incident, no matter the extent of the injury.
Below are the major steps you should take:

1. In the case of a major injury or fatality, fi rst seek medical atten-
tion for everyone in need;

2. After the injured are cared for, ensure the facility is secure and
that no one else can be harmed or injured;

3. Do not disturb the scene, except to perform fi rst aid and/or to
prevent further injuries;

Vol. 37, No. 3, Winter 2011 6 Employee Relations Law Journal

Safety, Accidents, and Investigations

Employee Relations Law Journal 7 Vol. 37, No. 3, Winter 2011

4. Report the incident to government agencies, as required by
law. OSHA requires the reporting of any injuries or illnesses
that result in death, loss of consciousness, days away from
work, restricted work activity or job transfer, or medical treat-
ment beyond fi rst aid. Verify reporting timelines for your appli-
cable jurisdiction; and

5. Once the scene is secured and the proper authorities have
been notifi ed, the employer should immediately conduct an
internal investigation.

Accidents should be fully investigated by the employer. The investi-
gation team should include both management and employees. Setting
up and training the investigation team before an accident will allow for
immediate action. An investigation should include, at a minimum:

• Interviews with those who witnessed the accident and/or who
have relevant knowledge of the event;

• Visiting the site where the incident occurred (it is important
to remember that until the site is released by all agencies
involved, you cannot move anything except to provide fi rst aid
or to prevent another accident);

• Review of your company’s existing accident prevention plan;

• Review of existing protective and safety equipment; and

• Review of manufacturer’s recommended uses and operation
manuals for any equipment involved in the accident.

The quality of your internal investigation can affect the outcome of
any possible external investigation.

Once the internal investigation is complete, the employer must act on
what it has learned. This includes updating the plan to refl ect the results
of the investigation. Failure to act on what is learned from the investi-
gation could expose employees to potential hazards and lower morale,
while also exposing employers to potential citations and fi nes. It is rec-
ommended that you contact legal counsel to address internal investiga-
tions and the anticipated external government agency investigations.

STRATEGICALLY HANDLE EXTERNAL ACCIDENT
INVESTIGATIONS

The sight of an agency investigator can bring stress to any workplace.
If you have a well planned approach on how to address these investiga-
tions, you will go a long way toward reducing that stress.

Safety, Accidents, and Investigations

Vol. 37, No. 3, Winter 2011 8 Employee Relations Law Journal

In situations where there is a mandatory investigation by an enforce-
ment agency, such as in a fatality investigation, contact your legal coun-
sel early in the process. This allows you to get legal advice from the very
beginning of the investigation and not have to spend time back-tracking
once the matter moves to possible citations and fi nes.

OSHA investigations are usually in response to an accident or com-
plaint. They may also be prescheduled as a routine check or follow-up
to a previous investigation. You cannot ignore OSHA or state program
inspectors when they arrive for an investigation. Any delay in allowing
the agency access to the facility may result in creating an adversarial
response from the agency. You need to ensure that you have a strategy
in place should you be investigated, and consider involving legal coun-
sel in that strategy.

Investigations can result in citations, fi nes and in some cases, jail time.
This makes a plan even more critical. An investigation by OSHA or your
state program inspector will have four basic components:

1. The opening conference;

2. Document request;

3. Employee and management interviews; and

4. A closing conference.

In addition, if citations are issued, there could be a subsequent appeal.

The Opening Conference

When OSHA or the state program inspectors arrive, they must con-
duct an opening conference with management and employees. As the
employer, this is your fi rst opportunity to fi nd out the reason for the
investigation. This may be straight forward, for example, you had an
accident OSHA is investigating, or obscure, for example, OSHA received
an anonymous complaint. Regardless of the reason, OSHA is there. This
is your opportunity to start a dialogue with the agency. At the opening
conference you should be able to determine how the agency intends to
conduct the investigation and get an indication of the potential issues
that may be raised. OSHA has six months from the opening conference
to complete the investigation and issue any citations.

Records Requested by the Inspectors

During the investigation, OSHA or the state program inspector will
ask you to produce your current plan. This request will include several
parts of the plan, including those sections that relate directly to the
accident or the complaint being investigating. While the focus will be

Safety, Accidents, and Investigations

Employee Relations Law Journal 9 Vol. 37, No. 3, Winter 2011

on the accident or complaint, the investigation can, and most likely will,
reach beyond the single incident.

Most inspectors will seek to have these documents produced in an
expedited manner. While you want to be cooperative, you do not have
to blindly follow the timeline that the inspector sets. You have the right
to review the records before they are produced and to have the records
reviewed by your attorney for confi dentiality issues. You may also want
to consider designating some documents as trade secrets, which may
prevent their disclosure to third parties. Remember, any document pro-
duced to a government entity becomes a public record subject to public
disclosure requests .

During the document production phase, you will want to ensure you
are providing only those documents requested. It is not uncommon for
an employer to produce more material than requested, and then fi nd
out the extra material it provided resulted in an expanded investigation.
The inspectors are not operating in a vacuum. They can and will expand
an investigation beyond the original complaint/accident if they believe
a possible violation exists.

Interviews with Employees and Management

Simultaneous with the records request, OSHA or the state pro-
gram inspector will move forward with employee and management
interviews. These interviews will, at a minimum, include employees
who were exposed or injured, and supervisors and key management
members responsible for safety and health at the company. Everyone
interviewed has the right to have legal counsel or an employee repre-
sentative present. If a union is involved, then the union will likely have
an employee representative present at each member’s interview. Those
interviewed can request to have a manager or legal counsel present as
well. It is important to work with your employees so they feel comfort-
able if they make this request.

The inspector will attempt to limit who can be present during the
interviews. This should not deter an employer from requesting the
opportunity to be present at all interviews. Management should never
go into an interview with an inspector without legal counsel. Regardless
of when and where the interview takes place, it is considered to be
on the clock. You must allow the interview and you must pay for the
employee’s time spent in the interview.

The Closing Conference

Once OSHA or the state program inspectors complete the investiga-
tion, they will hold a closing conference. This is when they will provide
the employer with the results of their investigation. In some jurisdic-
tions this can be as detailed as providing you with a draft of the actual

Safety, Accidents, and Investigations

Vol. 37, No. 3, Winter 2011 10 Employee Relations Law Journal

citations they intend to issue. This is the opportunity for the employer
to provide any additional materials to show why the citations should not
be issued. It is not, however, the time to argue why a particular citation
is incorrect.

During this conference, the employer should attempt to gather as
much information as possible about why inspectors believe there is a
potential violation. This is your opportunity to conduct informal discov-
ery. At the end of this conference, an employer should have a good
idea of what citation the agency will issue and the evidence supporting
those citations.

Appeal of the Citations

Once citations are issued, you have a short time to appeal or request
an informal or reassumption hearing. Since everything said at these
informal hearings can be used against you in the formal appeal, it is
recommended that you have legal counsel at any such hearings and
during any subsequent appeals.

Remember, the time you spend developing a safety program today
is an investment that will save your company money and increase
employee morale in the long run. When an accident does occur, follow-
ing the steps provided above will change your company’s experience
from that of a potential train wreck, to that of a slight detour, enabling
you to more easily get your company back on track. Do your part to
ensure your company is prepared for the unexpected.

Copyright of Employee Relations Law Journal is the property of Aspen Publishers Inc. and its content may not

be copied or emailed to multiple sites or posted to a listserv without the copyright holder’s express written

permission. However, users may print, download, or email articles for individual use.

www.asse.org SEPTEMBER 2014 ProfessionalSafety 53

When I was an OSHA compli-ance officer, I performed sev-
eral fatality investigations. One of my
early investigations involved a fatality
in a grain silo. The silo’s bottom part
had an auger that transported corn.
The corn had formed a crust over
the auger and prevented the flow of
corn. Two teenage cousins entered
the silo to shovel the corn to another
opening in the side of the silo. They
had to walk on top of the 15-ft pile of
corn to do so.

While they moved the grain to the
side opening, they dislodged the crust
above the bottom auger. As corn began
to funnel through the bottom auger,
the flow created a whirlpool effect and
the boys could not escape. It was as
if they were stuck in quicksand. They
screamed for help but the response was
too slow. One boy stood on a board
on top of the corn holding his cousin’s
hands as he was sucked into the grain
funnel. He could not hold him and he
watched as his cousin was pulled into
the corn where he suffocated.

The incident happened in the early
1990s, and I remember the investiga-
tion as if it were yesterday. I had to
relive the incident in an interview with
the surviving cousin. That was one of
the hardest conversations I ever had
because I could picture every word he
described and I could feel the pain he
felt for his loss. My memories of the
investigation are vivid; but can you
imagine how vivid the memory is for
the cousin who lived?

Incident investigations are designed
to answer the question “why” so that
we can prevent future incidents. No
one wants to investigate an incident
because it is a reminder that injuries
impact people. An investigation process
is vital to the success of any SH&E
program because it turns a reactive pro-
cess into a proactive tool. Investigation
processes driven by systematic urgency
and discipline prevent future problems
when they identify the real cause of the
problem—and management takes ac-
tion to solve the problem(s). We learn
from mistakes to avoid future inter-
views similar to the one I had with the
survivor.

What characteristics do great investi-
gation programs have? Great programs
maximize the benefit of four critical
stages in an investigation process.

Stage 1: Reporting
Organizations cannot correct what

they do not know. Effective incident
investigation programs encourage per-
sonnel to report all incidents, including
first-aid injuries, recordable injuries and
near hits. When a workforce embraces
the importance of reporting, it has an
opportunity to correct small problems
before they escalate to larger issues.
Had the grain silo investigated near hits
earlier, would the outcome have been
different? Successful organizations
create a transparent work environ-
ment where employees want to share
the potential risk they observe so that
the company can make adjustments to
prevent future injuries.

Incident reporting also has differ-
ent dimensions. There is the initial
report from the injured employee
to the supervisor, then there are the
notifications from the supervisor to the
appropriate leaders in the organization.
Both elements are important. Supervi-
sors cannot correct a problem they do
not know about, and management
cannot demonstrate its commitment
to sustainable improvement without
knowledge of the issues. Communi-
cation from the injured employee to
leadership creates awareness and focus
on injury prevention.

Critical Considerations
Employers should implement several

critical practices with respect to inci-
dent reporting:

–
ing all incidents (e.g., first aid, record-
ables and near hits).

reporting. Workers should feel free to
share what they experience.

quickly workers should report inci-
dents.

will be notified in the organization for
all situations. Include time frames for
how quickly people should hear about
incidents.

each step of the process.

Stage 2: Investigation
Effective investigation involves more

than filling out a report or checking
boxes on a form. A paper exercise does
not facilitate long-term improvement.

that surround an incident. Multiple
prepackaged investigation tools are
available that can help identify root
causes. However, the brand on the tool
does not make the process successful.
The most successful investigation tool
is the one that gains the full support
of the company’s leaders. All layers of
an organization must understand the
process and provide their collective au-
thority to make it successful. Manage-
ment support is more important than
the investigation tool itself.

Become an expert on the collection of
information and analyze the impact of
each detail. For example, evaluate steps

focus on the immediate circumstances
that surround the event. Look up-
stream and determine what steps (and

a road map from the start of the injured
worker’s day (or before) to the moment
of the incident. The goal is to create a
storyboard that explains, step-by-step,
how and why conditions and behaviors

–
tions exist for a reason. Investigators
should peel back the layers of every
step to determine what led to the event.

A good investigator collects detailed
data in stages and organizes notes so
that s/he can write a coherent report
with ease. The key is to ask questions
about each step to populate the event

sense to the employee and document
everything related to the step.

Incident Investigations
Four Critical Stages

By David G. Lynn

When a workforce
embraces the
importance of

reporting, it has an
opportunity to correct
small problems before

they escalate to
larger issues.

Best Practices

54 ProfessionalSafety SEPTEMBER 2014 www.asse.org

Critical Considerations
An effective investigation explores

several critical points when analyzing
each step of an event; describe ex-
amples of:

employee;

step;

impacted

each step;

each step;

step;
–

ed each step.
Utilize the value of multiple perspec-

tives to answer the appropriate ques-
tions. The employees, direct supervisor,
manager and senior manager should
always participate in the investigation
process; other subject-matter experts
or employee representatives should
participate as well. If the supervisor
and manager fail to participate, they
minimize their accountability for the
incident and their lack of visibility
contributes to a negative safety culture.
Active participation from leadership
establishes the importance of the
incident.

Stage 3: Corrective Action
Make sustainable corrective action

your goal. The investigation phase
will paint a storyboard that led to the
incident. Each step in the storyboard
represents an opportunity to change
the outcome. Corrective actions should
address elements of the storyboard that
failed or contributed to the incident.
Sustainable corrective actions change
the appropriate details throughout the
sequence of events.

How do you put corrective actions in
place? The event analysis will usually
reveal a series of unwise choices or
contributory causes that led to the final
poor decision that caused the incident.
The contributory causes can also in-
clude latent organizational weaknesses.
Corrective measures should address the
source of these weaknesses.

Critical Considerations
When applying corrective action, con-
sider the following critical points:

the storyboard with sustainable correc-
tive actions.

measures address any similar circum-
stances.

on the log.
–

rections.

progress.

term improvement.

Stage 4: Communication
The communication phase is easy

to overlook. Once the investigation
is over and the problem is solved, the
natural reaction is to move on to the
next challenge. Great programs maxi-
mize the knowledge gained from the
incident experience and communicate
the lessons learned. Incidents should
not happen in a vacuum, and leaders
should tell others about the event to
help ensure that a similar incident does
not occur. The communication goal is
to learn from the incident experience
and prevent future incidents by com-
municating what happened.

Make Lessons Learned Memorable
Following are several ways to make

lessons learned memorable:
–

pen to them.

share a personal example of how it ap-
plies to the audience.

–
quences. Share examples of related in-
juries and the impact it has on families.

people to think about the incident
throughout the day.

and feel the impact of the incident.

Conclusion
The same incident should not hap-

build an incident investigation process
around the four pillars: report, investi-
gate, correct and communicate. When
organizations invest in a full circle pro-
cess that focuses on the small things,
they can turn a reactive process into a
proactive tool.

grain silo were the first to experience
such a situation? Was that the first time
corn had crusted over an auger? Was it
the first time they had to use alterna-
tive methods to remove grain? Was it
reasonable to think that the corn would
dislodge at some point? What would
have happened if the company had
investigated previous near hits—if it
had recognized the potential for future
incidents through past investigations?
Most certainly the situation could have
been different if the company had.

Minor incidents that occur every day
have the potential to become future
tragedies. Investigate the small things
with relentless consistency so that you
do not have to conduct hard interviews
like I did with OSHA.

When organizations invest in a full circle process
that focuses on the small things, they can turn a

reactive process into a proactive tool.

David G. Lynn, CSP, is a vice president of Signature Services, a division of Life & Safety Consul-
tants. He is a professional speaker, author and improvement strategist with 20 years’ experience.
Lynn’s books include Principle to Practice and Strategic Safety Plan. To learn more, visit www
.lifeandsafety.com or www.david-lynn.com.

Best Practices

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9
9

Copyright of Professional Safety is the property of American Society of Safety Engineers and
its content may not be copied or emailed to multiple sites or posted to a listserv without the
copyright holder’s express written permission. However, users may print, download, or email
articles for individual use.

1

Course Learning Outcomes for Unit III

Upon completion of this unit, students should be able to:

3. Apply accident investigation techniques to realistic case study scenarios.
3.1 Explain the steps necessary for an effective accident investigation.

Reading Assignment

Chapter 4:
Using the Analytical Approach to Investigate Accidents

Chapter 5:

Investigative Techniques

In order to access the resources below, you must first log into the myWaldorf Student Portal and access the
Business Source Complete database within the Waldorf Online Library. To reduce the amount of results you
receive, it is recommended to search for the article by title and author.

Hughes, B. (2009). Incident investigation: Evidence preservation. Professional Safety, 54(10), 55-57.

Lynn, D. G. (2014). Incident investigations. Professional Safety, 59(9), 53-54.

Rinker, R. C. (2005). Organizing investigative interviews. Claims, 53(4), 26-28.

Unit Lesson

Investigation is a Process

Most safety practitioners have seen accident investigation reports that read like this one below:

 Description of accident:
o Employee cut finger on unguarded saw blade

 Accident cause:
o Employee removed saw guard

 Corrective action:
o All employees retrained on the proper use of machine guarding

Certainly, the fact that the blade was unguarded resulted in the injury. However, there are many other
questions that arise: Why did the employee remove the guard? Did the employee really remove it, or was a
guard not available? Have other employees operated the saw without the guard? Have there been similar
injuries? Will retraining make any difference—especially if there is no guard available? Are there
administrative consequences for removing the guard?

It should be evident that our simple accident scenario is anything but simple, but many investigations never
get past the most obvious causes. Training or retraining is often the only action taken to prevent a recurrence.
Imagine what might be overlooked in a more complex accident scenario. Ensuring that accidents are
thoroughly investigated, all possible causes are identified, and effective corrective actions are taken is the
purpose of the accident investigation process.

Calling an accident investigation a process implies that it is a planned, systematic effort. Remember that

UNIT III STUDY GUIDE

Investigative Techniques

2

UNIT x STUDY GUIDE

Title
accidents are statistically rare events, and it is critical for an organization to have a well-defined, documented
investigation process. How an investigation will be conducted should not be decided on the way to the
accident scene.

Defining the Process

Accident investigation is a linear process; each step should be completed before moving on to the next. A
simple model of the process uses three steps, which are as follows (Oakley, 2012):

1. Gain knowledge.
2. Analyze the knowledge.
3. Develop corrective actions.

For our unguarded saw blade accident example, the unanswered questions would indicate that the “gain
knowledge” step was not completed before the other two steps were accomplished. One might wonder if any
analysis of the knowledge took place at all. A limitation of this model is that it stops at the development of
corrective actions. Corrective actions must actually be implemented, and after implementation, the actions
must be evaluated for effectiveness (Lynn, 2014). This may seem obvious, but it is surprising how often an
investigation becomes a paper exercise with no actions taken. It is also important to communicate throughout
the organization the results of the investigation and the actions taken. “Make workers imagine, think about,
and feel the impact of the incident” (Lynn, 2014, p. 54).

Accidents by definition are unplanned and unanticipated, and to ensure the investigation process is
responsive and dynamic, adequate preparation is needed (Oakley, 2012). A clear, written policy on accident
reporting and investigation procedures should outline goals and responsibilities. A written emergency
response plan identifies the first responders for on-scene medical care and outlines the initial securing of the
accident scene. Employees responsible for accident investigation must be trained in the investigation
procedures and provided with the necessary tools and equipment. All employees in the organization must be
trained on the importance of accident investigation and the procedures for ensuring all accidents are reported.
An unreported accident is a missed prevention opportunity.

Gaining Knowledge

It is not possible to answer the
question of why something
happened without a complete
understanding of what
happened. This understanding
is gained through the gathering
of evidence. Dividing the types
of evidence into four
categories is helpful; the “four
Ps” are as follows (Oakley,
2012):

 Physical evidence includes
the materials and objects at
the scene of the accident.
Where these materials are
located on the scene and their
condition are important facts.

 Paper evidence includes
policies, procedures, logs,
checklists, and any other

written information related to the accident. Of course, many of these documents may be in electronic
form, but we still think of them as paper evidence for the sake of the “four P” concept.

 People evidence includes the statements and interviews of people that may have relevant knowledge,
such as those who are directly involved, witnesses, and first responders. Supervisors and managers
are also important sources of this type of evidence.

The accident investigation sequence
(Oakley, 2012, p. 39)

3

UNIT x STUDY GUIDE

Title

 Photographic (picture) evidence includes photographs and videos taken of the accident scene, as
well as photos or videos that may have been taken of the same scene or the surrounding area before
an accident. In the era of digital photography, this type of evidence is often available from a wide
variety of sources—not just a photographer dispatched to the scene.

Whenever possible, the accident investigator or the investigation team should be directly involved in gathering
the evidence—especially for the people component. Perhaps you have played the party game where the
players are arranged in a line, and the first person whispers a message to the second person. The second
person repeats the message to the third, and this continues until the last person receives the message and
announces it to the entire group. Often, what the last player announces is substantially changed from the
original message. The more people in the line, the more likely that the message changes. The same
phenomenon is likely to happen with information about an accident. Critical consideration of the source
should be applied to any evidence provided by persons outside the investigation team.

What evidence would you want to gather for our unguarded saw blade accident? For physical evidence, you
could examine the saw for other mechanical defects. If a guard was available, you would want to know how
easily it attaches to the saw. You might be interested in the layout of the shop, the equipment, and the
housekeeping in the area. For paper evidence, you would look for the operator’s manual, any policies or
procedures published by the organization related to the saw operation, and training records. For people
evidence, you would want to interview any witnesses as well as other shop employees and shop supervisors.

How much evidence is collected and how much time is devoted to gathering evidence can be guided by the
impact of the accident (Hughes, 2009). Was a fatality involved? Were there multiple injuries? Has the same or
similar type of accident happened in the past? Will there be a substantial cost to recover from the damages?

The Next Step

As noted earlier, accident investigation is a linear process, and following the sequence is important. Once the
evidence is gathered, then we can proceed to the next step of analyzing the knowledge we have gained and
begin to answer the important question of why the accident happened. In the next two units, we will learn
about various ways the evidence can be analyzed to determine causal factors.

References

Hughes, B. (2009). Incident investigation: Evidence preservation. Professional Safety, 54(10), 55-57.
Lynn, D. G. (2014). Incident investigations. Professional Safety, 59(9), 53-54.

Oakley, J. S. (2012). Accident investigation techniques: Basic theories, analytical methods, and applications
(2nd ed.). Des Plaines, IL: American Society of Safety Engineers.

Suggested Reading

If you are interested in learning how to create and maintain an accident prevention plan, as well as exploring
how to use it to respond to accidents, read the article below. Not only does the article discuss these topics,
but the article also touches on how to respond to external investigations.

In order to access the resource below, you must first log into the myWaldorf Student Portal and access the
Business Source Complete database within the Waldorf Online Library.

Battles, R. A. (2011). Safety, accidents, and investigations: Be prepared for the unexpected. Employee
Relations Law Journal, 37(3), 3-10.

4

UNIT x STUDY GUIDE
Title

Learning Activities (Non-Graded)

Search the accident investigation reports at the U.S. Chemical Safety Board (CSB) website
(http://www.csb.gov), and find a report that interests you. Read through the report, and make a list of all of the
evidence that was collected by the investigators. Categorize each item of evidence according to the four Ps
(physical, paper, people, photographic). Which type of evidence appears to have had the greatest influence
on the conclusions of the investigators?

The purpose of this activity is to help you study and learn the concepts taught in this unit. This is a non-
graded activity, so you will not submit it. If you experience difficulty in mastering any of the concepts, contact
your instructor for additional information and guidance.

http://www.csb.gov/

IMS INVESTIGATION fly Richard C Rir

Organizing Investigative
Interviews
/ / T ^ OSS, got a second? I have three inter-

K ^ views set tomorrow and I need some
– L r advice. They are on three completely

different kinds of accidents. One is a meat cutter
who cut his hand badly on a band saw, one was
involved in a traffic collision, and one is a secre-
tary who fell off a chair at work.”

“It sounds pretty straightforward. What can I
do for you?”

All accidents could be

divided into three causation

factor categories: human,

vehicle, and environmental.

“I want to maximize the amount of informa-
tion I get from each interviewee, obviously, hut I
also want to maximize my efficiency in obtaining
that information. Can you give me some guid-
ance to help me get the most information in the
least amount of time?”

At fir5t glance, these injuries would seem
totally unrelated, and would require different
approaches to the interviews. They all have seyer-
ol traits in common, however.

In the early 1970s, the National Transportation
Safety Board developed a guide for the investigation
of acddents. NTSB found that all collisions and
adverse events could be broken into three time peri-
ods: pre-inddent, incident, and post-inddent. All
accidents also could be divided into three causation
factor categories; human, veliicle, and environmental.

Causation Factors
Human factors include the drivers of all

involved vehicles, operators of any machinery or
equipment, pilots, secretaries who tall from
chairs, and witnesses. Human factors encompass
anyone and everyone who has anything to do
with the incident. This could include supervisors,
trainers, managers, and co-workers.

Device or vehicle factors pertain to the man-
ner in which the device caused the event, be it a
pipeline, railroad car, or aircraft. For a machine
operator, this would include design factors, safety

2 6 ! APRIL 2 0 0 5

devices, alterations to devices, interior contact
points within vehicles, prior device failures, and
repair and maintenance histories, as well as how
well the device reacted to the event.

The third causation factor is the environment,
which takes into consideration whether the area in
which the event occurred contributed to the event.
For a slip and fall incident, for example, the inter-
viewer would want to know what the surface was
made of. Was it clean, dry, level? When was it last
serviced? For a traffic collision, what is the accident
history of the area? Are there traffic controls? Did
they fimction? Were they necessary? In what way
was the area altered by the incident?

Time Periods
The pre-incident period starts with the design

of the device involved in the injury, the initial
training of the injured party, and the design of the
workstation, and continues up to the moment at
which the event became unavoidable. Questions
an interviewer might ask to obtain information
related to this time period include:

Does the meat cutter have any formal food
service training? Where did he receive it? When
was the particular saw purcliased and by whom?
Had he ever used this kind of machine before?
Had he ever been cut before?

When did the driver first receive his license?
What driver training had he received? When did
he first buy the car and from whom? What dam-
age did it have at the time? Had it been involved
in any prior collisions? What traffic controls were
present? Were they functioning and visible?

How long had the secretary been using this
chair? Was it a new chair or a replacement? How
long had he been working at the particular compa-
ny, or in this assignment or at this workstation? Had
he ever noticed anything irregular about the chair or
the floor? To whom did he report it, and when? Had
he been injured previously? How did those prior
injuries occur? What were the lighting conditions?

An example of pre-event information would
be a reference to Ford’s production of the Pinto in
the 1970s. The Pinto developed a reputation for
being involved in numerous fires upon rear-end
collisions. During tbe ensuing litigation, it was
found that certain design features might have
contributed to the fires.

Richard Rinker is an

investigator for

MJM Investigations,

based in Raleigh.

N.C.

CLAIMS

FIGURE 1

9-Cell Accident Investigation Matrix

Pre-event Event Post Event

Human

Device

Environment

Of particular interest in automo-
bile collisions are questions about
prior collisions and damage, brake
application prior to impact, distance
moved by both vehicles as a result of
the collision, and at-rest positions and
separations of the involved vehicles.
for all claimants interviewed, ques-
tions should be asked regarding factors
present at least in the 24-hour period
prior to the injury, including sleep pat-
terns; drug and alcohol use, both pre-
scription and recreational; interperson-

al relationships; financial situation;
and work conditions.

The incident period is that imme-
diately following the point of no avoid-
ance. That is, the moment at which the
operator is committed to becoming
involved in the event. For our injured
meat cutter, it would be the time at
which he no longer could pull his
hand out of the path of the blade, for
a driver of a vehicle, it is the time at
which he no longer has the ability to
avoid the collision by braking or turn-

2 8 A P R I L 2 0 0 5

ing. For our secretary, it is the time at
which he began to sit in the chair.

The incident period continues
until the event stabilizes: when the
meat cutter has sustained the maxi-
mum injury, when all damage has
occurred and the vehicles have come to
rest, when the secretary is on the floor.

The post-incident period Is the
time from the end of the incident
phase, and continues until the situa-
tion is completely returned to its pre-
event condition. This includes medical
treatment, litigation, vehicle repair,
claimant retraining or rehabilitation,
device redesign, or operator retraining.
This time period could extend several
years. In the event of a lifetime disabil-
ity, it could continue for decades.

Questions pertaining to the post-
incident period would include when
medical treatment first was sought,
where treatment was obtained, and
who referred the claimant to the med-
ical provider. Can the claimant describe
the facility and the provider? When
was treatment discontinued? Was he
released, or did he stop on his own?

Ibgether, these factors and time
periods can be combined into a nine-cell
accident investigation matrix, as seen in
Figure 1. Dividing the incident into
three time periods allows an interviewer
to focus and organize his questions.
Breaking down the causation factors and
time periods enables the interviewer to
conceptualize the factors that led up to
the incident and its subsequent events.

The specifics of the interview are
up to the imagination of the interview-
er. The more inventive and inquisitive
the interviewer becomes, the more
information he will elicit. Use of the
nine-cell matrix provides interviewers
with a tool to organize interviews, effi-
ciently categorize questions, and maxi-
mize the information obtained, while
minimizing the time required to obtain
the information. In any event, a thor-
ough, in-depth interview can require
an hour or more to conduct.

Organizing the interview keeps
the information in an orderly format.
Readers of the finished reports can
find specific information quickly and
decisions can be made more effective-
ly. The interviewer is less likely to
become sidetracked and omit relevant
questions, and the time spent conduct-
ing the interview is reduced, A

CLAIMS

Brian Hughes

The
importance
of evidence
collection

and preser-
vation
can be

overpowered
by other

priorities.

Incident Investigation:
Evidence Preservation

Looking back at your last incident investiga-tion, did you experience anything similiar orwere you faced with any of these dilemmas?
•While attending to the needs of injured and dis-

tressed employees, time-sensitive evidence was
missed.

• While securing the area and bringing it back to
a safe mode, circumstances that could have served
as evidence had to be altered.

•In the bustle to minimize costly downtime,
resuming production rushed the evidence collec-
tion process.

• A piece of critical evidence
disappeared.

•The legal department
wished it had more to demon-
strate due diligence.

•A regulatory body’s
requirement or request could
not be fulfilled.

In tlie rush to return to a
state that resembles normalcy,
the importance of evidence
collection and preservation
can be overlooked or over-
powered by other priorities.

Evidence is critical to any incident investigation
because it is the data that support the conclusions
of the investigation. The primary intent of an inci-
dent investigation is to identify effective solutions.
To accomplish this, the investigation needs to
uncover causes and how they relate to one another.
Evidence provides support for what the team con-
cludes to be causes, it cultivates a level of confi-
dence that correlates directly to the quality of the
evidence collected. Evidence is the foimdation for
an investigation—for the investigation team as well
as for others reviewing fuhue investigation results
and conclusions.

Many companies do not have a formal evidence
preservation policy in place, so the process is ad
hoc—left up to the investigator or individuals on
the team. Some highly regulated companies, with
the nature of their governing regulations, specify
requirements for evidence documentation. They
tailor their evidence preservation policy to match
the requirements of the regulatory agency. But evi-
dence documentation is not necessarily the same as
evidence collection or preservation. Regulatory
requirements must be considered. However, a poli-
cy can be developed that fulfills the objectives of
the investigation and the requirements of regulato-
ry agencies.

It is best to decide how to handle evidence
before an emergency occurs. Develop an evidence
preservation policy based on the organization’s

needs and distribute it to everyone who will have
the responsibility to carry it out. Include it in train-
ing curriculum so pc\iple are familiar with the
process before they actually need it.

What follows are guidelines that any company
can use to develop a simple evidence preservation
policy to help ensure that evidence is managed
effectively throughout an investigation.

Step 1: Assess the Significance
Ask a few simple questions to dtxument the

actual and potential significance of the problem.
Try not to overreact to a rela-
tively benign problem, but try
to accommodate the require-
ments of an incident that has
major significance.

The following questions
\\’iil help assess the signifi-
cance of the problem.

1) Safety: Were fatalities
and/or injuries involved?

2) Environmental impact:
Did a major environmental
release occur?

3) Revenue: What was the
impact on revenue?

4) Costs: What additional expenses were
incurred?

5) Erequency: How often has this type of prob-
lem happened in the past?

6) Other: Different firms will have unique signifi-
cance factors to capture, such as regulatory impact,
supplier quality rating, employee confidence, drain
on customer service department and public image.
These should be identified and considered.

Determining risk adds a different, yet potentially
important, piece of data to the significance assess-
ment. Risk assessment needs to be balanced with
its intended outcome. It can be a complex process
involving probabilities and statistics that yield
powerful predictions. Or, it can be a simple process
of combining individual scores of probability multi-
plied by consequence. The simple process is still
highly subjective, but it is quick and understood
easily.

However, complexity does not ensure that a
model is actually predictive. Either way, remember-
ing that any actual outcome exists within a range of
possibilities is important. Simply considering the
likelihood that the outcome could have been worse
may be enough. For example, if it is reasonable to
assume that someone could have been killed, usu-
ally this is enough of an assessment to qualify the

Best Practices continued on page 56

www.asse.org OCTOBER 2009 PROFESSIONAL SAFETY 55

ices M
contitmed J

i from page 55

investigation as being extremely impor-
tant, upping the ante regarding the for-
mality of evidence preservation.

Impact may also be related to the
product or process involved. Will the
evidence gathered present a
risk to compromising the com-
pany’s intellectual property?
Often, the company has an
interest in maintaining confi-
dentiality regarding an inci-
dent and a thorough evidence
preservation policy will sup-
port this. Assessing the impact
allows the investigator to
gauge the appropriate ap-
proach to preserving evidence. The more
significant the eveiit, the more thorough
the evidence presen, ation approach.

The legal department has the respon-
sibility to protect the company against
litigation, as well as to litigate on behalf
of Üie company. The purpose of an inci-
dent in\’estigation is to identify what
happened to prevent recurrence. These
two functions sometimes seem at odds.
The legal department should not control
the course of an investigation, but it
should control how the information pro-
duced by the investigation is managed.
In addition, the department should be
involved as soon as possible to ensure
the evidence presen.’ation steps align
with the responsibility to protect the
company’s integrity.

Step 2: Secure the Scene
When possible, secure the scene of the

incident. This gives the investigation
team the opportunity to document evi-
dence and gather information before it is
disturbed. This can be crucial to an accu-
rate root-cause analysis later. Depending
on the incident, you may be required to
grant access to additional parties, such
asOSHAorCSB.

Get the legal department involved
right away to determine those who are
authorized to access the area. Tape the
area off and allow access only to author-
ized personnel. Assign an area gatekeep-
er who is responsible for keeping a log
of those who enter the controlled area.
This log should include the name, com-
pany, time in and out, and purpose of
entry. If these individuals remove evi-
dence, document it thoroughly (see Step
3). Evidence removed may not be physi-
cal—it may be pictures or notes. If neces-
sary, identify a secure room in which to
store the evidence.

Step 3: Document &
Secure the Evidence

Evidence will come in many forms.
Maintain confidentiality and secrecy
when required. Ensure that evidence is
released only to authorized individuals.
A log sheet should be used and include
the following items.

Evidence ID Number
Assign a unique idenfification num-

ber that will be associated with a certain
piece of evidence from that point forward.

Relative Timing
What was happening relative to the

event? Even if the process seems benign
at first, you need to know what was
happening in the facility leading up to
and following the event.

Procedures
What procedures govern the activities

leading up to and following the event?
Are these procedures accurate and up to
date? Were they followed? Why or why
not? it is important to understand the
procedural controls and whether they

are effective.

When possible, secure the scene of the
incident. This gives the investigation

team the opportunity to document
evidence and gather information before

it is disturbed.

Date
What time and date was the evidence

collected?

Location/Source
Where was the evidence collected?

Physical Evidence
Document physical evidence as accu-

rately as possible where the evidence
was found. Depending on the signifi-
cance of the event, creating a map of the
affected area may be useful. Evidence
locafion can then be documented rela-
tive to the incident locafion.

Statements
Statements should be taken fi^m wit-

nesses. Document each person’s name
and contact informafion, as well as
his/her locafion relafive to the incident.
This is an inifial interview, and you may
need more informafion once the formal
root-cause analysis is underway.

However, the interview should be
conducted by someone familiar with the
root-cause analysis process. This will
help ensure that quesfions elicit causes
as much as possible and minimize state-
ments that are jaded by opinion, loyal-
fies, etc. Ensure that proper protocol is
followed. Hourly staff may require
union representafion. Human resources
and other departments may need to be
involved. Protocols for interviewing
employees may be nœded as well.

Computer Data
Ensure that computer data leading up

to and following the incident are protect-
ed. You may need to idenfify a system
expert to help understand what informa-
fion is available and how to interpret it.
If possible, get the raw data as well as
any screen prints or strip charts. Care-
fuUy note the timing of data captures rel-
afive to the incident.

Work Orders
WTiat is the state of the

maintenance on the system?
Are maintenance work orders
open or up to date? When was
the last time maintenance was
performed on the equipment?
Was it conducted according to
specificafions? Were there any

changes in parts/materials sourcing?
When is the next maintenance acfivity
scheduled?

Equipment
What is the state of the equipment? Is

it in good operafional shape? Is it being
used in accordance with its intent? If
not, why not? Include equipment data,
such as asset numbers and otber rele-
vant data.

Photos & Video
Photos and video are extremely useful

forms of evidence. Automatic photos or
video, such as from a security camera,
need to be documented and secured.
Take numerous photos—do not worry
about using them all. Illustrate scale of
objects photographed, even compared to
something as simple as a hotel key card.

Samples
Take product samples as soon as pos-

sible. This may be helpful later in deter-
mining the exact state of the product at
the fime of the incident.

Dateñlme Checked Out
List the date and fime the item was

checked out.

Checked Out By
List the person who checked out the

evidence. Include contact informafion.
Ensure that only authorized individuals
are able to check out evidence.

DateHime Checked In
List the date and time the item was

checked back in.

Distribution List
If any item has been copied and dis-

tributed, maintain a list of people to
whom the item was distributed.

The recommended steps are not
exhausfive. Individual companies will

56 PROFESSIONAL SAFETY OCTOBER 2009 www.asse.org

find themselves gathering different
types of evidence based on what is perti-
nent and available.

Regardless, an evidence log will be
invaluable later if chain of custody needs
to be proved, or if the root-cause analy-
sis is reopened for further evaluation or
assessment.

Step 4: Destruction of Evidence
Sometimes it is necessary to destroy

e\ idence after an investigation is com-
pleted. While some investigations will
require the evidence to be held in perpe-
tuity, most will not. Storing electronic
files is easy and does not take up much
space. However, storing physical parts
and equipment may not be necessary.
The legal department should advise
regarding evidence maintenance.

Step S: Refine the Evidence Policy
lÉ is safe to assume misktakes might

happen the first time. Conduct a post-
investigation review to determine
improvement opportunities. Refine the
policy based on lessons learned, and dis-
tribute to the organization.

Evidence preservation is crucial to
any incident investigation. Approach
evidence presen-ation according to the
actual and potential significance of the
problem. E)eveloping and becoming

5 Steps of Evidence Preservation
These guidelines can help any company develop a simple evidence preserva-
tion policy to ensure that evidence is managed effectively throughout an
investigation.

1) Assess the significance.
•How serious is the problem? More serious problems require more stringent

evidence management.

2) Secure the scene.
•D(x:ument and control access.

3) Document and secure the evidence.
•Catalog evidence and maintain chain of custody.

4) Destroy evidence?
•Most evidence does not need to be kept forever. Work with legal staff to

develop a destn.iction schedule.

5) Refine evidence policy.
•Learn from experience, roll lessons into policy, share with others.

familiar with a formal evidence preser-
vation policy tailored to the organization
will ensure that personnel have the data
required to complete an accurate analy-
sis—the only path to identifying true
causes and pinpointing solutions that
effectively reduce risk and prevent
recurrence.

Brian Hughes is vice president of Apollo
Associated Services. He has led incident inves-
tigations related to major explosions, chemical
releases, consumer product contamination,
manufacturing defects and supply ctiain
processes. For more information, visit umnv
.apoUorca.com or contact him at bhughes
©apolhrca.com: (206) 331-2569.

PS oniLiniE
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issue date to find articles covering topics ranging from program development,
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