Incident Investiagations and Forensic Photography

MichaelA.Taylor,ARM
4/1/16
IncidentInves+ga+ons&
ForensicPhotography
MichaelA.Taylor
[email protected]
Disclaimer
Thispresenta=onisintendedtobeinstruc=onal
andinforma=onalonly,notlegaladvice.
Inves=gatorsareencouragedtofollow
establishedagencypoliciesandprocedures.
Anyques=onsorconcernsaboutan
inves=ga=onshouldbedirectedtoyourCity
AGorneyorLocalCounsel.
[email protected]
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Best Practices Incident Investigation Report Form
ο Injury - First Aid Only
ο Injury - Medical Treatment
ο Property Damage
ο Near Miss - Record Only
Exact Location where Incident Occurred:
Date of Incident:
Time:
AM
PM
Date of Report:
Who Was (or could have
Employee
been) Affected:
Non-Employee
If Employee, Length of Employment
Current Job Title or Occupation:
Length of Time in Position:
Name of Department Normally Assigned to:
What Property (if any) Was Damaged:
WITNESSES (Name All Witnesses to the Incident and obtain statements from each):
RISK POTENTIAL (How severe was the accident and how often could it happen if improvements are not
made?)
Major
Frequent
Severity Potential:
Serious
Frequency Potential:
Occasional
Minor
Seldom
DESCRIPTION (Step-by-step, describe the actions, events, conditions, and decisions that led to the
incident.):
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Revised 02/03/2016
Best Practices Incident Investigation Report Form
SUMMARY – Describe the incident (photos and/or sketch may be necessary).
ANALYSIS – Describe conditions that led to the incident (environmental conditions, tools/equipment used,
task being performed, etc.).
SYMPTOMS - Describe the Unsafe Conditions that existed AND the Unsafe Acts that contributed to the
event:
ROOT CAUSES - Keep asking what caused or allowed this condition or practice to occur until you get root
causes.
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Revised 02/03/2016
Best Practices Incident Investigation Report Form
JOB SAFETY ANALYSIS (JSA)
Is there a Job Safety Analysis (Written Safe Work Procedures) for the task that was
underway at the time of the incident?
YES
NO
If there is a Job Safety Analysis (Written Safe Work Procedures) for the task that
was underway at the time of the incident, is there a signed copy of the document in
the employee’s file?
YES
NO
NA
If there is no Job Safety Analysis (Written Safe Work Procedures) for the task that
was underway at the time of the incident, should there be?
YES
NO
NA
RECOMMENDATIONS / CORRECTIVE ACTION - Describe any controls and/or corrective procedures that
may prevent reoccurrence of similar incidents. What has and/or should be done to control the root causes
listed (add responsible person’s name beside each action):
MANAGEMENT SYSTEM IMPROVEMENTS – Describe measures taken by management to improve the
system and prevent reoccurrence of similar incidents (employee training, new equipment, changes in safety
policies, changes in operating procedures, etc.).
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Report Completed by:
Date:
Report Reviewed by:
Date:
Report Approved by:
Date:
Revised 02/03/2016
Best Practices Incident Investigation Report Form
Sample Incident Investigation Interview Questions
WHO
1. Who was injured?
2. Who saw the accident?
3. Who was working with the injured party?
4. Who had assigned the person to the work task?
5. Who had trained the person on the hazards and protective measures for this task?
6. Who else was involved?
WHAT
1. What were the causal factors of the accident?
2. What were the injuries?
3. What was the person doing when injured?
4. What had the person been instructed to do?
5. What tools was the person using?
6. What machinery was involved?
7. What training had been given?
8. What specific precautions were necessary?
9. What protective equipment was being used?
10. What protective equipment should have been used?
11. What will be done to prevent a recurrence?
12. What safety rules were in place to prevent this type of accident?
13. What safety rules were being followed?
14. What were the environmental conditions (i.e., lighting, floor surface, etc.)?
WHEN
1. When did the accident occur?
2. When did the person start this task?
3. When was the person assigned to this department?
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Revised 02/03/2016
Best Practices Incident Investigation Report Form
4. When were the hazards of the operation addressed?
5. When had the supervisor last checked on job progress?
WHERE
1. Where did the accident occur?
2. Where was the person at the time of the accident?
3. Where was the supervisor at the time?
4. Where were fellow workers?
HOW
1. How does the injured employee feel now?
2. How did the injury occur?
3. How could this accident have been prevented?
WHY
1. Why was the person injured?
2. Why did the person do what they did?
3. Why wasn’t protective equipment used?
4. Why weren’t specific instructions issued?
5. Why didn’t the person check with the supervisor when they noted things weren’t as
they should be?
6. Why did the person continue to work under these circumstances?
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Revised 02/03/2016
MichaelA.Taylor,ARM
4/1/16
Forensics
•  Inthe18thcenturywhentorturetoachieve
confessionswascurtailed,criminal
inves=ga=onbecameamoreevidence-based,
ra=onalprocedure.
•  FromtheLa=ntermforēnsis,meaning"ofor
beforetheforum.”Accusersandaccused
wereallowedtopleadtheircasesinfrontof
thepublicforum.
Huh?
•  Forensicinves=ga=onreferstotheuseof
scienceortechnologyintheinves=ga=onand
establishmentoffactsorevidence.
•  NOTatelevisionprogramlikeCSI,CSI:Miami,
andForensicFiles…butkindof.
•  Thereisforensicnursing,forensicsocialwork,
computa=onalforensics,forensicaccoun=ng,
forensicanthropology,forensicphotography,
amongothers.
Incidents
•  Anyunplannedeventthatresults,orcouldhave
resulted,ininjuryordamages
•  Incidentsdon’tjusthappen,theyarecaused
•  AccidentsaretermedINCIDENTSun=l
determinedotherwisebytheCourts
•  Thousandsofaccidentsoccurthroughoutthe
UnitedStateseveryday
•  Canbeminortosevere
•  Allincidentsshouldbeinves=gated
•  Mostaccidentsarepreventable
[email protected]
2
MichaelA.Taylor,ARM
4/1/16
Incidents
•  Incidentsusuallyresultfromunsafeactsand/or
unsafecondi=ons
•  Analysisnormallyrevealsacause
•  Directcause–usuallytheresultofoneormore
unsafeactsorcondi=ons,orboth
•  Indirectcause–usuallytraceabletopoor
managementpoliciesordecisions,ortopersonal
orenvironmentalfactors
•  Inves=ga=onsareintendedtodeterminecausein
anefforttopreventrecurrence,nottoplace
blame
Inves=ga=ons
ForensicInves=ga=on
•  Allwearelookingforisascien=ficapproachtoan
inves=ga=on
•  Amethodical,research-basedinves=ga=onintothe
facts
•  Basisofaroot-causeanalysis
•  Scien=ficmethod
–  Collec=ngevidence
–  Gatheringandanalyzingfacts
–  Developinghypothesis
–  Tes=ngeachhypothesisagainstthefacts
–  Mostprobableexplana=on
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3
MichaelA.Taylor,ARM
4/1/16
Process
•  Haveaplantodetermine:who,what,when,
where,why,andhow
•  Analyzetheinfluenceofeverythinginvolved
intheincident-Materials,Machinery,
Equipment,Tools,Chemicals,Environment,
Worksta=ons,Facili=es,People,Policies,
Procedures,Task,Management,Workload,
andPeople
•  Reviewallsourcesofinforma=on
Process
•  Managementisresponsibleforthesafety,health,and
well-beingofworkers
–  WereallPolicies,Procedures,Rules,Guidelinesinplace?
–  Weretheyfollowedandenforced?
–  Wastherepropersupervision?
–  Waspropertrainingprovided?
–  Werefirstaidproceduresinplace?
•  Materials,Machinery,Equipment,Tools
–  Wasthepropertool(s)used?
–  Wastheequipmentusedproperly?
–  Wasthemachineryinspectedadequately?
–  Weresafeguardsinplace?
Process
•  Environment,Chemicals
–  Wasweather(heat,cold,light,etc.)afactor?
–  Werehazardousmaterialsinvolved?
•  Facili=es,Workspaces
–  Wasthedesignappropriate?
–  Wasthespaceadequate?
–  Wasallequipmentmaintainedproperly?
•  People,Task,Workload
–  Werejobrequirementsmet?
–  Anyphysicaloremo=onalimpairments?
[email protected]
4
MichaelA.Taylor,ARM
4/1/16
Process
• 
• 
• 
• 
• 
• 
• 
• 
Iden=fyprecedingeventsandcondi=ons
Inspectthesite(securetheloca=on)
Preparesketches
Takephotographs
Interviewvic=mandwitnesses
Determinepossiblesequencesofevents
Determinelikelysequenceofevents
Preparesummaryreport
ForensicPhotography
•  Canbeveryeffec=veprovidingevidencein
almostanyclaim–slipandfall,vehicle/
equipmentincident,dogaGack,orotherincident
•  Paintapicture/tellastorywiththephotographs
•  Photographscaneliminatedoubtandrefresh
memories
•  Pictureshelpreconstructtheaccidentscene
•  TakeLOTSofphotos,usethebest,
ForensicPhotography
•  Thinkaboutwhatyouwouldwanttoseeifyou
knewnothingabouttheincident
•  Setthestagewithbroadview(e.g.streetsignsor
landmarks)
•  Photographallangles(360°view)
•  Moveintoclose-uppicture
•  Labeleachphotowithdateandloca=on
•  Usevideowithnarra=onifpossiblealongwith
photographs.
[email protected]
5
MichaelA.Taylor,ARM
4/1/16
100 Feet
50 Feet
100 Feet
10 Feet and
Reverse
50 Feet
10 Feet and
Reverse
V2
V1
10 Feet and
Reverse
10 Feet and
Reverse
50 Feet
50 Feet
100 Feet
100 Feet
Interviews
• 
• 
• 
• 
• 
• 
• 
• 
Rememberfact-findingpurpose
Treatpeoplewithrespect
Addresstheemo=onsinvolved
Watch(andwatchfor)bodylanguage
Avoidaccusatorytone
Don’tinterrupt
Listenac=vely–repeatwhatyouhear
Endposi=vely–explainnextsteps
Interviews
•  Getpreliminarystatementsassoonas
possible
•  Ques=onWho,What,When,Where,Why,
andHow
•  Askwhy,why,why,why,why?
•  Useopen-endedques=ons
•  Alwaysbeprofessional
•  Re-interviewwitnessesasnecessarytoresolve
conflic=ngaccountsoftheincident
[email protected]
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MichaelA.Taylor,ARM
4/1/16
InterviewDon’ts
• 
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• 
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• 
• 
• 
Usevoice/videorecorderwithoutpermission
Askleadingques=ons
Interruptthewitness
In=midatethewitness
Blame
Judge
Contradict
Documenta=on
Documenta=on
•  Ini=alIncidentReport
•  Regulatoryrepor=ngrequirements
–  OSHArecords,
–  Agencyreports,
–  Insuranceno=fica=ons
•  Inspec=onrecords
•  Maintenancereports
•  Trainingrecords
[email protected]
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MichaelA.Taylor,ARM
4/1/16
Inves=ga=onReport
•  Background
–  Day,date,=me,loca=onofincident
–  Environmentalcondi=ons
–  Peopleinvolved–names,contactinforma=on,posi=on,etc.
•  Report
–  Sequenceofevents
–  Extentofinjuryordamages
–  Typeofaccident
•  DiscussionAnalysis
–  Directcauses(energysources,hazardousmaterials,etc.)
–  Indirectcauses(unsafeacts,unsafecondi=ons,etc.)
–  Basiccauses(policies,personalorenvironmentalfactors)
•  Iden=fytheRootCause
•  MakeRecommenda=ons
–  Topreventfutureoccurrence
THANK YOU!!
[email protected]
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