Event Investigation Guidelines

• Step Three:  Discern / Investigate Facts

This is where you will gather information for analysis in Step Four. We have created tools to help you through this phase of the process. We have provided links to .pdf versions of associated tools where appropriate. Please feel free to use them in your investigations. We also provide customizable interactive simple-to-use tools that will speed up your data gathering and sifting process. For more information on these tools, click here.

Following are our recommended data gathering and sifting steps to provide you with the best opportunity to discern fact from non-fact, and to collate information for Step Four Analysis.

1. Conduct a review of pertinent data and documentation. Use the Data / Document Review Checksheet as an aid to ensure that all appropriate information is gathered / reviewed.
2. Conduct initial interviews of involved / appropriate personnel. Consult the Guide to Effective Interviewing for insights on how to maximize the quality of information gleaned during the interview process. Individuals to consider for interviews include:
   1. Personnel present during the event, either at the event location or in another location that was either involved in or witnessed indications / consequences of the event.
   2. Personnel who directly responded to the event or event consequences.
   3. Additional personnel who might have been directly involved in pre-event activities that could have affected the event.
3. When human error is involved or suspicioned, conduct a Human Error Review in accordance with the Human Error Review Guideline.

   The Human Error Diagnostic Form provided within the Human Error Review Guideline provides interface for direct data input into the Performance Enhancement Matrix (PEM). The PEM is a corrective action database that allows you to quickly and easily input information. Moreover, the PEM allows you to easily identify trends and uncover hidden weaknesses that are causing mistakes. For more information, click here.

4. If you have access to information on previous events (either internal to your organization or within your industry), conduct a Previous Occurrence Evaluation using the Previous Occurrence Evaluation Guideline. Doing such a review can provide substantial insight regarding the causes of previous events, as well as to identify when previous actions taken were not effective.

   By entering data in the Performance Enhancement Matrix (PEM), you will be able to easily identify any previous occurrences of similar events.

5. Conduct an overview evaluation of data and interview information accumulated to determine if additional data gathering or interviews are necessary. Claims by interviewees should be validated using multiple sources of information.