Gathering and Analysing Evidence

I was recently involved in an investigation into an incident where a worker had sustained crush injuries, I was called in about a week into the investigation and after reading witness testimony, studying photographic evidence and visiting the location of the incident I suspected that there was a different story to be uncovered to the one that was being shared. Something felt ‘off’. 

Although no two clients are the same, we’ve been involved in enough incident or ‘unwanted outcome’ investigations to have identified a few common themes when it comes to investigation process gaps.

So I thought it would be helpful to take you through our own “Paradigm Investigation Model” and in this second blog in my Investigation series I am going to share how we gather and analyse evidence.

This series of blogs is meant to offer you some ideas about how you might be able to improve your investigation process, so even if you only focus in on one or two specific areas for improvement, you’ll be amazed at how the quality of your investigations can increase significantly. 

Let’s go back to our ‘crush incident’.

Several people had been moving a heavy piece of equipment into place when the incident occurred and from the statements taken, it all seemed pretty clear; worker places himself in the line of fire during a lifting operation, despite having been trained, briefed, given a risk assessment and method statement, etc., etc.. Human Error – job done!

But then we started challenging some of the evidence, asking more questions, digging a bit deeper to understand the ‘context’ of the task and looking for answers. REALLY looking.

How had the piece of equipment got onto the 1st floor walkway - 60ft off the ground - with no hoist, crane or other lifting device in sight, in the first place?

Why were the worker’s injuries on the lower back rather than at the top of the legs where the photos suggested he had been trapped? Why did it take so long to summon a first aider?

We re-interviewed a couple of the key people including the injured person and asked them to provide lots more detail. It turned out the load had been manhandled up the staircase by the team as there was no lifting equipment available; during this task the load had slipped crushing the injured person against the handrail, thus explaining the position of the injuries! 

Why is this important? The wrong information would have gone into that final report; the corrective actions wouldn’t have prevented a reoccurrence because the wrong causal factors were being addressed and this is something we see time and time again with clients who claim to have repeat incidents and don’t know how to prevent them.

This is central to the whole process of gathering & thoroughly analysing evidence.

So let’s dive in!

After a serious event, it’s often the case that an organisation goes into a state of shock - a state of temporary leadership paralysis, with mixed feelings of sadness and sometimes utter despair.

It’s not surprising. We’re only human, after all.

And this environment can put even the most competent investigation teams under real pressure.

They have a job to do - but they are acutely aware of the heightened emotions of the people they most urgently need to speak to.

Despite this, it is critical that evidence is gathered as soon after the event as is practicably possible.

It can be massively challenging to be part of a team investigating a serious incident - mentally, emotionally and physically. So it’s vital to check in regularly with your investigation team, and to bear all of this in mind when selecting them. Make sure you have things in place to help them cope – like access to counsellors, support groups and workplace mental health champions.

And of course, if the event has been significant enough to warrant police or regulator intervention, then the incident scene itself may be classed as a crime scene. This will (of course) mean that it is out of bounds to our own investigators until it’s released.

What exactly is Evidence?

Well – the Oxford English Dictionary defines evidence as “the available body of facts or information indicating whether a belief or proposition is true or valid”. We typically see investigation reports which have solely focused on so called ‘facts’. There is nothing wrong with getting all the ‘facts’ but it’s very often another type of information that gets lost, dismissed or overlooked and that is the CONTEXT. Facts tell you how and when something occurred, context usually tells you why!

Let’s look at the types of evidence we should be gathering and analysing in more detail.

Tangible Evidence

Certainly, we’ll be looking for a whole range of physical items such as:

·     Broken or damaged fixed plant, equipment and/or infrastructure;

·     Damage to the local environment, like as fire or flood damage;

·     Tools and equipment being used in the activity, like ladders or screwdrivers;

·     Chemicals & substances;

·     Barriers & fall protection;

·     Warning signs;

·     PAT test stickers

·     And so on.

We might need to quarantine large pieces of equipment or plant for inspection by experts - like scaffolds, forklift trucks and production lines. 

Every reasonable effort should be made to ensure that the investigation team have undisturbed access to this equipment – AND that it is securely stored, until they agree to release it.

Documentation

We’ll also begin to collate any documentation relevant to the task or activity. Things like:

·     Procedures;

·     Safety plans;

·     Work instructions;

·     Risk assessments;

·     Permits;

·     Method statements

·     And so on.

We should request training records, competence assessments and trade test results - not just of those immediately involved in the incident, but also of those involved in the activity. This includes anyone who set them to work; issued a permit; or visited the job before the incident occurred.

Scene of the Incident

Like our story at the start – with the crush injuries – it’s critical to record full information about the scene of the incident.

Sometimes you can learn more about an event and the safety standards at a workplace by thinking outside of the box.

 Look for clues:

·     What is out of place? 

·     Is anything missing? 

·     Is anything here that shouldn’t be?

And don’t forget to:

·     Take measurements + identify the weights of things (if relevant);

·     Pick up small items nearby that might form evidence;

·     Take photographs + draw sketches;

·     Establish access and egress points and routes;

·     Record details of other work parties and activities in the vicinity;

·     And look at other permits issued on the same equipment and the associated works.

Witness Statements

In my last article, we talked about how to protect the witnesses. We know that witness interviews should be done as soon as physically possible after the incident.

(In my next article we’ll talk about how to conduct witness interviews in detail).

But now, we’re looking at WHO we need to interview - and why.

It’s very easy to decide that we need to interview any people directly involved in the event. 

We also probably know that we need to interview any witnesses in the vicinity.

But there are the other people you should consider, as part of your witness interview programme:

?          Permit Issuer

?          Supervisor

?          Line Manager

?          Individual who set the working party to work

?          Author of Method Statement and Risk Assessment

?          Department Head

?          Specialist Trainers

?          Next of Kin

?          Handover team/s

?          Control room personnel

?          Production Line Managers

?          Stores Person

?          Equipment maintainers

?          Equipment manufacturers and designers

?          Previous similar incident investigators

?          Retired or ex-employees

?          HR

?          Occupational Health

Now, this list might seem long – but each of these people has a story to tell (we’ll discover how to open that story up next time!)

Procrastination Point

Procrastination Point is normally the place where a client has got to in an investigation, when they reach out to us. 

We often arrive to find a disengaged, tired out investigation team. They’ve typically spent between a week to ten days busily collecting evidence, interviewing witnesses and fending off senior management who need answers. 

And they’re now looking at a LOT of conflicting, confusing information - evidence, witness testimony, technical data, test results and so on - but don’t know how to move forward from here.

Many investigation teams are never taught the art of analysis!

Once the team reaches Procrastination Point - and in our experience more than 95% of teams do - we advise our clients to have a Sponsoring Manager Intervention. This supports the team; helps them to re-energise; and most importantly, ensures that they have everything they need to continue.

The team MUST start to make sense of (or analyse) the information and start to make some decisions.

Many organisations do not have clear protocols for delegated decision making - which can create a stumbling block for an investigation team, who need to make decisions about causal factors and corrective actions!

 To analyse investigation evidence, we use a technique called ‘Event Causal Factor Analysis’ (ECFA).

This involves working through each piece of evidence in a methodical way - inspecting, reading, challenging and comparing it to other evidence - and highlighting any inconsistencies. 

Where inconsistencies are identified, we go back over our notes and findings. If necessary, we re-interview specific witnesses to validate the information as far as we can.

And then, we use our validated facts to construct our Primary Sequence Timeline. We overlay this with our contextual information - secondary events and conditions - to provide a visual representation of the whole event, from start to finish.

The next step is to use the Primary Sequence Timeline to identify critical steps (points of no return), causal factors and root causes. Of course, we’re also interested in understanding the presence of human error in events, and whether people were set up to fail or succeed by the organisation.

We often use the ECFA to talk senior managers through the investigation timeline. It’s a powerful tool, not only in demonstrating how the event unfolded, but also in showing them that the investigation has been conducted professionally and in depth.

Often, we advise investigation teams not to decide on or issue corrective actions until the management have been talked through the ECFA.

The obvious exception to this are immediate safe guards and the extent of condition risk management (which we’ll come back to in a future article!) But this method does often make corrective actions so much easier to agree and capture, with top level buy-in and sponsorship.

If you’ve found a successful solution to investigating incidents in your organisation, then we’d love to hear from you. And of course, we’d love to support you if you haven’t!

 To learn more about everything we’ve talked about, just visit www.paradigmhp.com or call +44(0)1600 887 228.

 And you can always reach me personally at [email protected]!

 Until next time

Teresa