Event Investigation Guidelines

Following are some guidelines for you to consider should you have a significant event to investigate. Be sure to check out the Tools part of this section, where you will find a collection of the best investigation tools available anywhere.

• Process Overview

There are eight basic steps to conducting a Root Cause Analysis (RCA) investigation. These steps are identified in the following diagram:

• Step One:  Preserve Scene and Gather Data

When you have had an event occur, it is important that you initiate the investigation as soon as possible to avoid such things as loss or misplacement of physical and/or documentary information. In addition, first hand reports of event participants and witnesses tend to alter with time due to stress, rationalization, "comparing notes", and poor or inaccurate memory. When mobilizing an investigation team, your team members must not only have adequate expertise and adequate availability of time to conduct the investigation, but also must be able to come together quickly to initiate the effort.

When practical and appropriate, scene preservation should commence as soon after the event occurs as possible. While these will vary with the nature of the event, some items for you to consider include:

• Delay cleanup to allow for recording of the event scene
• Begin to capture information immediately to prevent loss or elimination through cleanup efforts
• Photograph or videotape the scene
• Record as-found locations of significant accident-related materials
• Record names (and badge numbers as appropriate) of individuals who were involved in or witnessed the event
• Collect individual recollections of the event and of the activities in which the individuals were participating at the time. Consider collecting written statements in this initial stage
• Interview individuals as soon as possible, preferably before they leave work for the day
• Take pre-teardown photos that demonstrate scale and orientation of key elements at the scene