Quick Checklist for Investigators Incident Investigation Guideline

Quick Checklist for Investigators

Even for experienced investigators, preparing to investigate a significant incident can be hectic in the mobilization period following the event. This checklist is intended to be used as a quick reminder of some key considerations for people on their way to an investigation. Incidents are unique and have unique requirements but the information included should be adequate reminders for most incidents.

Physical Items
Photographic Equipment 35mm camera Digital camera Video camera Film and batteries for cameras Measurement Tools Tape measures o 100 feet o 10 feet 6 inch steel ruler Inside calipers Outside calipers Documentation Aids Dictaphone Notebooks Clipboard Pens and pencils Laptop computer Evidence Marking Aids Paint pens Grease pens Permanent markers Tags with wire or plastic connectors Orange flagging tape Evidence tag stickers Tweezers Forceps Sample bottles

Personal Protective Equipment Hard hat Safety goggles Steel toed shoes Fire retardant coveralls Gloves Hearing protection Other Cell phones Electric circuit tester Multi-purpose tool (pliers, knife, screwdriver, etc.) Compass Magnet Duct tape Mirror Small pocket mirror CCPS Incident Investigation book Sticky notes Sticky flags Flashlights Magnifying glass Barricade tape

Evidence Collection Aids Self-closing plastic bags

2003 AIChE - CCPS

Quick Checklist for Investigators Incident Investigation Guideline

Action Reminders
Controlling the incident is first priority. Until Incident Command has extinguished fires, evacuated injured personnel, completed a headcount, and contained spills/stopped releases, the control of the incident is first priority. Secure the scene. As soon as possible, protect the scene of the incident from disturbances. Work through operations, maintenance, and emergency response personnel to ensure the scene is not disturbed. Establish a system to limit and control entry into the area. Time sensitive evidence is a high priority. Gathering evidence that might deteriorate with time should be a high priority. o Many electronic systems record data from operating units and then delete that data after a specified period of time, often 24 hours or less. o Some evidence such as char patterns, surface fractures, or volatile chemicals spills can degrade as a result of weather conditions (rain, wind, or sunlight) Establish roles and expectations for the investigation team. Roles and expectations need to be defined early so that there are no misunderstandings. o Is the incident investigation team also the primary point of contact with outside agencies such as OSHA, EPA, and CSB? o What expectations do local management and corporate management have for the investigation team for timing, interim reports, final reports, and defining requirements for startup of units or equipment? o What resources are available and just as important, what resources are not available? Interviews need to be done promptly. Memories fade with time and are influenced by discussions with other witnesses. Interviewing techniques are important. o Plan the interview. Do not do it haphazardly. o Interview one person at time and in a private comfortable setting. Use only one or two interviewers. o Set the interviewee at ease. One method is by asking questions about activities prior to the incident. o Be sensitive to the interviewees emotional state. o Do not express opinions. o Do not lead the interviewee. Ask questions that allow the interviewee to describe the incident in their own words. Questions should be neutral, unbiased, and nonleading. o Do not interrupt the interviewee. o Use a plot plan to better understand the location of interviewee the location of people and activities the interviewee saw movement of the interviewee o Ask what the interviewee saw, heard, felt, and smelt before, during, and after the incident. o Ask about timing/sequence of events to help develop the timeline. o At the end of the interview, ask for opinions about the cause of the incident or if the interviewee has anything to add that was not already covered.

2003 AIChE - CCPS

Quick Checklist for Investigators Incident Investigation Guideline

Gather information about the process early. The investigation team will need information about the process. Gathering the information can sometimes be done while waiting to gain access to the unit for physical inspection and data gathering. o Plot plans o Process description o P&IDs o Information about the chemicals in the area Follow established safety policies. Incident investigation team members should lead by example by strictly following site safety policies. Initial work is focused on what happened. Determination of root causes is important to prevent recurrence of the incident, but the initial focus of the investigation team is to define what happened. Capability of team members is critical. A major investigation needs the best people available to represent each needed discipline. Frequently contractors/consultants will be needed for special expertise. OSHA has specific requirements for the incident investigation teams. OSHA 1910.119 (m) (3) states: An incident investigation team shall be established and consist of at least one person knowledgeable in the process involved, including a contract employee if the incident involved work of the contractor, and other persons with appropriate knowledge and experience to thoroughly investigate and analyze the incident. Photograph the scene. Photograph overall views and specific items. o Decide if still photography is adequate or if video photography might be more helpful. o Photographs should be taken to document as-found location, orientation, and condition of items deemed to be evidence. o If many photographs are taken, a log of each photograph with information such as item, location, orientation, and date may be helpful. Establish a timeline. The investigation of almost every significant incident will require the development of a time line to depict the sequence of events before, during, and after the incident. Legal issues may be important too. Remember that on a serious incident the company not only has an incident to investigate, but also must be prepared for significant and costly litigation. Evidence that is removed from the scene needs to be secure. Facilities need to be made available to limit access to physical evidence that is removed from the scene. A system needs to be put in place to control entry to the evidence. Documents used in the investigation need to be secure. The investigation room needs to be secure. If investigation documents are stored in a room other than the investigation room, then that other room also needs to be secure. Determine the method by which evidence will be gathered. o Incidents with significant debris may require the establishment of a grid system to define the exact location of specific pieces. o Establish a method for documenting as found valve positions.

2003 AIChE - CCPS

Quick Checklist for Investigators Incident Investigation Guideline

Develop a list of potential scenarios and remain open minded. On complex incidents, it is sometimes helpful to develop a list of potential scenarios. Do not fall in the trap of only pursuing the initial obvious scenario. It is important to prove that the actual scenario did happen but it is also important to prove that other potential scenarios did not happen. References Center for Chemical Process Safety (CCPS), 1989. Guidelines for Technical Management of Chemical Process Safety. New York: American Institute of Chemical Engineers. Appendix C. Baker, Quentin A., Pierorazio, Adrian J., Ketchum, Donald E., Investigation of Explosion Accidents, Center for Chemical Process Safety International Conference and Workshop on Process Industry Incidents, October 2000, Orlando Florida. New York: AIChE, 2000.

2003 AIChE - CCPS