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Organizing an Investigation (Analytical Process (Analytical techniques…
Organizing an Investigation
Investigation Techniques
Components
Formal written policy
Reporting process
Investigation
goals
process
ERP training
Plan
Personnel
Respond
Care
Prevent more damage
Accident Investigation training
All employees
Reporting
Purpose
Investigators
Techniques
Accident investigation kit
Enables investigate ASAP
Tools
Investigative
Tape/cones
Tape measure
Flashlights/spotlights
Evidence bags/tags
Gloves/PPE
Administrative
Camera
Graph paper
Witness statemenst
Notepad
Technique/policy
Emergency Response
Secure scene
Care for injured
Manage BBP
Evidence
Preserve
Cordon area
Take/draw pictures
Interview Responders
Assess evidence
What?
Has it moved?
List
Witnesses
Equipment/material
Environmental factors
Time
Temp
Humid
Gather 4 "P"s
Physical
Is...
Large (building)
Small (debris)
Solid material
Tips
Positions/failure points
Graph paper sketch
Use expert
Measure
BBP
Note lack of PPE/guards
Categories
Visual
Testing
Placement/puzzle
Paper
Is...
Training docs
JSAs
Policies/procedures
Tips
Examine last
1 - Start @ low level
2 - Supervisor/Mgmt
3 - Corporate policy
Structure facts
People
Statement
ASAP
What they think...
Happened
Could prevent
Interview
ASAP
After medical
Separate
Tips
Explain why interview
Neutral/comfortable site
Notes/repeat facts
Contact info
Practice
Skills
Establish Comm
Explain
Interview purpose
Accident investigation
Do...
Collect other info (experience/training/etc)
Stay friendly/professional
Make feel important
Don't...
Rush
Rapid-fire question
Judge/suggest/refute
Questions
Specific
open-ended
Specific dates/times
Cause/prevention
End positive
Picture
Tips
Some "big picture" shots
Include reference object
Keep photo log
Before moving anything
Video
Before/during/after
Anything that will be removed
Timeframe
Varies
Re-initiate if needed
Analytical Process
Causal analysis
Ask Why (x5)
Accountability levels
1 - Worker/Equipment
Lowest Level
Equipment failures
Human error
2 - Supervisor
Define how to do work
Lack of supervision
Schedule/Comm issues
3 - Management
Dictates policies
Budgetary
Policies/procedures
4 - Corporate
Dictates culture
Most effective
Hazards v. Failures
Hazards
Cause injury
Correctable
Failures
Hazard if causes injury
Design/defect
Maintenance
Environmental factors
Analytical techniques
Events/Causal Factors Analysis
Change analysis
Barrier analysis
Analytical trees
Cause/Effect analysis
Benefits
Find low level & systemic
Consistancy
Facts --> Causal factors
Confidence in results
Objectives
Goal of interview
Evidence
Types
Preserve
Collect
Stop collecting
Causal analysis value
Analytical process value