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dipil
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Dear All ... Can we have a discussion on Incident Investigation? Can anyone come up with a definition to this? What all points we must cover under Incident Investigation?
From India
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Hello Dipil, Attached presentation that outlines a definition and aspects of the investigation process Regards
From Netherlands
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File Type: ppt Accident Investigation ESR 4-01.ppt (279.5 KB, 2117 views)

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Really, a very useful information is contained in this PowerPoint presentation. It will help us greatly in investigating and analyzing accidents, and we can also draw conclusions to prevent the same.

Thank you once again.

Arindam Ray
Asst. Manager P&A
GTZ (India) Pvt. Ltd.

From India, Calcutta
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dipil
730

Hi Ronald Mackenzie,

The presentation is very good... No doubt...

But I am a little disagree with a few points:

Your presentation says that we should include the names of the following in the report:

1. Injured worker/s or worker/s involved name/s
2. Name of Supervisor and Department

But, as far as I am concerned, we can give names of the persons involved in the incident in the preliminary report of the same... No need for any personnel names in the detailed Incident Investigation Report... By giving names, this may divert the entire purpose of an investigation... By giving a name, all will blame directly one person... This must not be the purpose of an investigation...

Finding out the key factors which lead to an incident and elimination of those to avoid recurrence must be the purpose of the investigation... Blaming anyone must not be the purpose...

A lot of things are missing in the presentation like who must investigate, how to investigate, which tool to be used for investigation, etc... However, overall the presentation gives a brief idea about investigation...

With regards,

Dipil Kumar V

From India
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dipil
730

Dear All,

The definition of Investigation is as follows: An investigation is a methodical, systematic, unemotional undertaking to collect and interpret information about an event to establish the extent of an injury or loss, why it happened, and to analyze the process involved to minimize the risk or prevent a recurrence. The investigation will normally result in the preparation of a logical, sequential report of the events with recommended preventive strategies.

With regards,

Dipil Kumar V

From India
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Re: Incident Investigation

Dear All,

It was an informative presentation on Incident Investigation. I conduct Accident/Investigation management training in Malaysia. The key point is the analysis of the findings to determine the root cause (normally a failure in management systems) and come up with solutions to prevent their recurrence. It is also important to ensure weaknesses in the system have been rectified so that similar or other incidents do not occur again.

I am attaching a presentation that I use for my training. I hope it will be helpful.

Thank you.

From Malaysia, Kuala Lumpur
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File Type: ppt Accident Incident investigation.ppt (872.5 KB, 1116 views)

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Dear all,

Very rarely does one find such a beautiful presentation and a relevant discussion with an excellent PowerPoint. My compliments to everyone for bringing an interesting topic to the forum.

I would like to share a perspective on the subject of incident investigation. As an Industrial Security Consultant with ten years of experience in the field, we often encounter incidents related to theft, pilferage, missing movable assets, and information security breaches. These issues are part of HR management.

We conduct thorough investigations into each incident, regardless of the outcome, which can range from one day to one month depending on the nature of the incident. The process involves a detailed study of the people, profiles, and systems within the organization connected to the incident. This exercise serves as an eye-opener for the organization, helping to reduce risks in protecting human capital and preventing potential security threats that could lead to property loss or misappropriation of funds.

If there is interest on this platform, I can share more insights.

Thanks,
V. Rangarajan

From India, Pune
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dipil
730

Dear All,

Thanks for the active participation in the discussion. Let us now select a specific subject under Incident Investigation. We will change the same and delve deeper as and when time allows and if all are interested.

As per your opinion, which is the best proven tool for Incident Investigation?

@ Gopinadhan Pillai...

The presentation is very good, a nice and knowledgeable one. Thanks for sharing.

@ V. Rangarajan...

We are here only because of the interest in discussion and thereby gaining knowledge. So, we request you to come up with your views and good postings.

With regards,
Dipil Kumar V

From India
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Dear Friends,

ACCIDENT INVESTIGATION …

CHARLIE’S ACCIDENT

Charlie had an emotional argument with his wife and proceeds to the local bar where he consumes several drinks. He departs the bar in his car at high speed. Minutes later, he loses control on the highway and is fatally injured. We know what happened; we must now determine ‘WHY’ it happened.

The investigation team is comprised of six specialists, each of whom has completely different perspective on the root safety deficiency.

1. Sociologist

2. Enforcement Officer from Liquor Control Board.

3. Pathologist.

4. High way Engineer

5. Automobile Engineer

6. Policeman.

The sociologist identifies a breakdown in interpersonal communication within the marriage. An enforcement officer from the Liquor Control Board notes the illegal sale of alcoholic beverages by the bar on a “two for one” basis. The pathologist determines that Charlie’s blood alcohol was in excess of legal limit. The highway engineer finds inadequate road banking and protective barriers for the posted speed. An automotive engineer determines that Charlie’s car had a loose front end and bald tires; the policeman determines that the automobile was traveling at excessive speed for the prevailing conditions.

Each of the deficiencies may result in a different definition of the underlying hazard.

Your final report with recommendtion to avoid recurrence please….

Kesava Pillai

From India, Kollam
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dipil
730

Dear All,

Among the team selected for investigating any incident, one should at least have the knowledge of Root Cause Failure Analysis. Recommendations should contain corrective as well as preventive actions. Furthermore, communication of the investigation findings along with these recommendations is a major part of the investigation process. Lastly, but most importantly, the follow-up is a crucial part of the process.

With regards,

Dipil Kumar V

From India
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dipil
730

Dear all,

Please let us have a specific discussion: Which is the best proven tool for incident investigation? Or which tool are you using for incident investigation?

Hope to have a good debate on this topic.

With regards,
Dipil Kumar V

From India
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Dear all,

From the perspective of security and risk reduction management, in my experience, I would like to share the following for the benefit of HR, Administration, and Security departments.

Usually, incidents of less significant nature do not occupy the attention of stakeholders unless these incidents occur with striking regularity.

Incidents involving any one or some:

1. Loss of calculators, desktop holders, stationery, small cash, timepieces.
2. Breakage of table glass without the knowledge of the occupant in a room in their absence.
3. Regular misplacement or loss of drawer keys or cash keys.
4. Regular damage to the drawer or any of the important cabins in the office.
5. Missing furniture or light systems without proper authority.
6. Regular missing of lights in the lift of the office.
7. Unusual expense patterns on housekeeping materials.
8. Unusual maintenance expenditure in facilities management or the storeroom.
9. Sudden missing of the company's scrap materials.
10. Discovery of unused or new company property in the scrap disposal.
11. Inordinate delay in receipt of returnable company equipment, items purchased originally by the department.
12. Non-maintenance of receipt and balance of returnable company materials sent for a specific purpose.
13. Regular opening of stores/materials department outside regular working hours.

A well-run organization may have a well-designed manual for each of the above areas. It is seldom followed because of a lack of supervision, control, and involvement, mainly due to a lack of integrity in the system itself. Because the system drives people and people drive the system.

All these are considered system lapses or administrative errors that do not get the due attention if there are no proper SOPs and NCRs. Usually, these events do not get escalated to the next level by the concerned for rectification.

Therefore, SOP and NCR are the first steps to prevent the occurrence of these incidents. Discussion may continue. We will discuss soon in the coming days.

Thanks and regards,

V. Rangarajan.

From India, Pune
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dipil
730

Dear Mr. V. Rangarajan,

Nice to share your rich experience with us... First of all, sorry for the late commend.

Let us consider a case - the theft of a laptop from the office within your area of monitoring. How will you proceed further? What techniques/tools will you use to investigate this case?

With regards,
Dipil Kumar V

From India
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Dear all,

Theft of property comes in two forms: movable and immovable. These properties must be handled following proper procedures and standard operating procedures (SOP). Documentation should strictly adhere to the prescribed format.

Procedures and the implementation of security rules and regulations must align with the policy design. Security, being a sensitive and critical department, is directly linked to Top Management. Any incidents related to theft, pilferage, or sabotage should be promptly and thoroughly investigated.

Conducting a detailed inquiry lacks a scientific tool or prescribed format in HR or Criminology to extract information from individuals. The offense originates in the mind and is executed by the human body. There are no scientifically established rules to identify criminal intent, as there are no qualifying criteria based on gender, race, religion, or academic qualifications.

Investigating a laptop computer follows a detailed method, varying from one organization to another. Some key questions and issues include:

1. How many laptops are in use?
2. Who is authorized to use them within the office premises or related work areas?
3. Who has access regardless of possession?
4. Policy compliance in case of loss or damage by users or non-users.
5. Access limitations.
6. Security procedures during usage, including entries, names, signatures, dates, times, and pass issuances.
7. SOP for usage during domestic and overseas travel.
8. Storage devices utilized by users.
9. Vendor access during maintenance and repairs.
10. Responsibility and accountability, with written agreements in case of loss or mishandling during transit.

In my experience, I have encountered instances of misuse, damage, and theft of laptops in leading organizations. Despite clearly defined rules, organizations often refrain from penalizing offenders. Typically, individuals involved in laptop theft are educated, tech-savvy, intelligent, and knowledgeable about security protocols, often using or facilitating the use of stolen gadgets in some way.

Companies frequently opt to report incidents to the police, anticipating the outcome and repercussions, leading to cases being closed and forgotten, with insurance claims as the resolution.

My approach to identifying suspects or offenders differs significantly in my experience.

Best regards,

V. Rangarajan.

From India, Pune
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Dear Friends,

Security and vigilance form another specialization. I am yet to come across safety officers being trained to do security and connected vigilance duties. I would prefer safety personnel to concentrate fully on their own area. For this, the safety fellow should be competent enough.

Acting as a master of all trades and poking their nose into other areas downgrades the profession. In fact, most organizations feel there is not much work for the safety personnel and entrust irrelevant duties to them. To please the management personnel, they accept such jobs. Such acceptance of other duties reinforces the management's opinion about safety personnel having not much to do. Of course, there are exemptions where safety personnel have no breathing time. This is also not professional. We should have a balanced approach and do justice to the profession. However, accident prevention and crime prevention are entirely different activities. Of late, workplace violence is included in the safety syllabus but not theft.

Regards,

Kesava Pillai

From India, Kollam
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Dear Friends,

We are yet to think of it in India, but a few other countries have found it essential and are seriously pursuing it, especially the USA. OSHA conducts training on the prevention of workplace violence, which is now a part of safety curriculum.

It includes:
1. Violence by Strangers
2. Client/Customers
3. Coworkers
4. Personal Relationships

Every employer should establish, implement, and maintain a written WPV Prevention Program. This program should be made available to all employees, including managers and supervisors. All employees should receive specific training regarding its content and implementation. The program should reflect the level and nature of the threats faced by the employees/employers. A review and assessment of the vulnerability to the four (4) categories of violence outlined previously is necessary for workplaces facing potential violence.

When violence may be committed by strangers, workers can be victimized both within and outside the traditional workplace while acting within the course and scope of their employment. The use of specific training, staffing, protective equipment, effective physical security methods, and policies must be reviewed and assessed.

Two basic types of violence by clients/customers against workers are of concern. The first type involves individuals with a history of violent behavior, such as prison inmates and mental health service recipients. Prevention focuses on appropriate staffing, specialized training, and other control measures. The second type occurs when clients or customers may become situationally violent due to frustration with delays or denial of benefits or social services. Prevention in such cases focuses on problem anticipation, appropriate training, and effective control measures.

Coworker violence can occur on several levels: between supervisors and subordinates or between non-supervisory and supervisory workers at the same or different levels. A well-written violence prevention policy that treats all employees fairly, training in conflict and dispute resolution, and active involvement of trained Employee Assistance Program (EAP) personnel are appropriate in these circumstances.

Finally, the potential for violence resulting from personal relationships must be considered. Estranged domestic partners may target their victims at their workplaces. Employees who may be victims of domestic violence need to feel secure in alerting their employers to the potential for a workplace attack. Strict policies should be implemented to address the confidentiality of personal employee information, restrict workplace access to employee relatives or outside visitors, and allow flexibility in the use of leave, work schedules, or transfers for at-risk employees.

To be successful, workplace violence prevention efforts must have commitment from top management and involve supervisors, employees, and employee representatives. Commitment and involvement are essential in any safety and health program. Management provides the organizational resources and motivating forces necessary to effectively deal with safety and security hazards. Employees should be involved, both individually and collectively, through participation in worksite assessment, assisting in the development of clear effective procedures, and identifying existing and potential hazards. Employee knowledge and experience should be incorporated into any written plan to correct and prevent safety and security hazards.

Ref: OSHA

Regards,

Kesava Pillai

From India, Kollam
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Dear Mr. Kesa Pillai,

It is not very often that we discuss something useful. Unlike other topics such as training, business opportunities, and immature questions and thoughts, your inputs are valuable and stimulate our minds for long-term processing in our daily lives.

Thanks and regards,

V. Rangarajan.

From India, Pune
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Dear Mr. Rangarajan,

Thank you, sir. I am glad that a few individuals like you, who have achieved high positions in the profession, are watching it. I will strive to be a part of this endeavor to impart what I have gained while in service and protect it from simply rusting.

Regards,
Kesava Pillai.

From India, Kollam
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dipil
730

Dear Mr. Keshav Pillai,

Thank you for sharing your knowledge.

Please review the following scenario: In the case of workplace violence, a Safety Professional who has a positive reputation among the workforce (instilling the belief that he is here to assist rather than punish) can play a crucial role. By being able to engage directly with a potentially violent group, he can effectively help to de-escalate the situation.

I would appreciate your insights on the above.

Warm regards,
Dipil Kumar V

From India
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Hi Dipil, Pls find the attached file of 'Investigating Chemical Process Incidents'.It may be useful for you.
From United States, Milpitas
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File Type: pdf Investigating Chemical Process Incidents - CCPS.pdf (6.22 MB, 282 views)

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i have information about acceident investigation i found it in the web search, i hope it help. Regards, samy HSE Qaroun petroleum Co. Egypt 00201227756820
From Egypt, Cairo
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File Type: pdf menu16-accedint investigation.pdf (85.1 KB, 203 views)

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I had prepared a procedure on Reporting & Investigation for an upstream O & G company in Sudan a few years ago. Maybe useful to some of the members.
From Malaysia, Kuala Lumpur
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File Type: pdf 009 - Accident & Incident Reporting & Investigation.pdf (516.6 KB, 471 views)

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Dear Ronald & Gopinadhan,

First of all, thanks for sharing the information. Accident investigation is a fact-finding report and not a fault-finding report. If we concentrate on the fault or putting blame, then the very purpose of the investigation fails. The accident investigation helps in finding the root cause and preventing such types of repetitive accidents in the nearby future. For this, corrective steps are needed to be strictly complied with.

Regards,

Deepak B Dorik
Sr. Manager-EHS
JBF Industries Limited

From India, Silvassa
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Basic accident investigation procedures include interviews, plans, photographs, relevant records, and checklists.

The process involves identifying immediate causes (unsafe acts and conditions) as well as root or underlying causes (management system failures), and subsequently determining remedial actions.

In an ideal scenario, an investigation should be carried out by an expert in accident causation, well-versed in investigative techniques, and possessing comprehensive knowledge of the work processes, procedures, individuals, and industrial relations environment specific to the situation. However, in reality, investigations are typically conducted by a manager from within the organization, with support from a member of the safety team.

It is crucial that the individual conducting the investigation remains impartial. Initiating the investigation with the intention of assigning blame invariably leads to failure. It is essential to recognize that even in seemingly straightforward accidents, there are typically multiple contributing factors.

During the investigation, particular attention should be given to various aspects, even if they are not immediately evident:

- Materials used by the employee
- Environment in which the individual was working
- Personnel assigned to the task
- Management's demonstrated commitment to safety
- Previous audits
- Physical evidence, and so forth

Thank you,
Sam

From Azerbaijan, Baku
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