Incident Investigation information gathering

The Causal Factors Chart is a formal, and systematic, incident investigation and root cause analysis technique. The technique depicts the events and conditions leading up to an incident. It combines critical thinking, logical analysis, and graphic representations to analyze and depict an incident event scenario. It helps strncture the analysis and data gathering processes to ensure necessary and snfficient information is collected. The CFC also has been applied to Root Cause Analysis. The CFC is sometimes referred to as the Events and Causal Factors (ECF) chart. The ECF chart depicts the necessary and sufficient events and causal factors associated with a specific incident scenario. 

The difference between a fatal accident and a near miss accident may onfy be a fraction of a second in time or a fraction of a centimetre in space. The information gathered from the investigation of near miss accidents assists us in introducing remedial measures to reduce potential hazards in the workplace. If we gather information about all accident and incident causes, we are able to take positive preventative action. 

Hazard identification and assessment including items such as what hazards must be identified, information gathering, workplace inspections, incident investigations, hazards associated with changes in the workplace, emergency hazards, hazard assessment and prioritization, and hazard identification tools ... 

Information derived from data-gathering activities serves as the basis for valid conclusions and recommendations. Without effective data gathering, the incident cannot be defined or analyzed effectively. In some cases, gathering data can consume most of the time and resources spent by the investigation team. Some teams report that it can take up to 70 percent of the investigation effort depending on the nature of the occurrence. 

Gather evidence from many sources during an investigation. Get information from witnesses and reports and observation. Get copies of all reports (documents containing normal operating procedures, flow diagrams, etc., maintenance charts, or reports of difficulties or abnormalities). Keep complete and accurate notes. Record pre-incident conditions, the incident sequence, and post-incident conditions. In addition, document the location of employee, witnesses, equipment, energy sources, and hazardous materials. 

When compiling the performance statistics an organisation will need to take into account the mechanisms by which it will gather the information. These should be reflected in the safety policy particularly in relation to reporting and investigation of safety events, incidents, accidents, etc. and its proactive monitoring, inspections, tours and audits. 

Blaming an individual or group of individuals for an injury-producing incident is not consistent with a systems approach to safety. Instead, an injury or near hit provides an opportunity to gather facts from all aspects of the system that could have contributed to the incident. However, most evaluations of near hits or injuries are incomplete, and are much less informative than they could be. Part of the problem here is the very term we use to describe the process—accident investigation. 

Identifying a potential risk is considered an opportunity to take a closer look at a particular area of operations, to have a dig around -to ask questions and review assumptions. But the information in the incident reports themselves rarely provides a sound basis for this. Incidents need to be acted on and further information needs to be gathered - something that is unavailable when reporting programmes are designed solely for the analysis, rather than the investigation, of incident reports (e.g. Wallace, Ross and Davies, 2003 Macrae, 2008). 

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