Page 5 - IAMI Review Issue 10
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Best Practice Investigation Tips
Members of IAMI all have great experience of investigation, but from time to time it is useful to share ideas and refresh ourselves as to best practice. The following list of investigation tips is not exhaustive, but has been culled from many years of incident investigations at all levels in a wide variety of industrial sectors including marine, port handling operations and in many high hazard industries from rail transportation to explosives manufacturing. Doubtless each of you will be able to add to the list from your own expertise.
10 Investigation Tips
1. Deine what you are investigating by writing an Incident Statement – what is the reason for the investigation? Start with the consequences of the event and what triggered it, i.e. its precursor.
2. Choose your investigation team carefully. Have individuals who can think widely and are able to challenge and evaluate initial indings.
3. Consider what has changed – no incident can occur without something being different.
4. What barriers and defences including controls have been defeated? – every organisation and vessel has deined procedures.
5. Interview witnesses – this includes people who were not directly involved such as supervisors, technical specialists, and others who may have some knowledge to contribute.
6. Have an open mind – anything could be possible and avoid jumping to conclusions and welcome naïve questions.
7. Use Post its and Charts so that the team can establish an accurate timeline of indings to help establish all of the causes that ran up to the incident.
8. Have an audit trail of indings, including all documents and photographs so that you have the necessary proof for the inal report.
9. Only proceed to a Root Cause Analysis when you have established all of the facts that contributed to the incident
10. Limit the number of your recommendations to those which can have a positive outcome and can be veriied when completed.
David Ramsay is the Managing Director of Kelvin TOP-SET Ltd conducting investigations around the world for the past 30 years. www.kelvintopset.com
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