Lawyer Monthly - April 2022

positive reinforcement to elevate safety awareness. Additionally, when a gap that raises a risk is discovered, leadership addresses the issue immediately without discounting it. An example of a tragic outcome resulting from an ignored risk is the 1986 explosion of the Space Shuttle Challenger. This catastrophic event was caused by the failure of two rubber O-rings due to record low temperatures. NASA managers disregarded warnings from engineers about the dangers of launching in cold temperatures. Because nothing happened during the first and second launch, it became the normality of complacency, and a bias was built around it. It is important that we consider different sets of eyes when facing a challenge or process as it can be difficult to recognise something different when it comes from the same circle of people. The IFO Group offers another set of eyes, and we can share experiences that help define the risks to be addressed. Generally speaking, what are the key steps in the incident investigation process? A structured approach to incident investigation helps ensure that all the causes are uncovered and addressed by appropriate actions. Step 1 – Secure the Incident Site. In the event of an incident, the first critical step is to secure the site. This helps make the area safe and preserves the scene to assist in recovering and protecting evidence. The IFO Group has experts who can act as an incident commander to take ownership of site and implement plans on behalf of the client. The site often needs to be stabilised or demolished before it can be entered. It is common for the area to be very unsafe and thorough planning goes into securing the site to protect people and assets. Step 2 – Plan the Investigation. Based on initial findings from securing the site, the team needs to work to confirm what expertise will be required for the material investigation. What resources will be involved? How long do you anticipate the investigation will take? Does the incident complexity require a single investigator or a team? Step 3 – Material Investigation. Once there is confirmation that the site is cleared without criminal activity and the right team is in place, the material investigation can begin. This step involves the collection of all relevant information related to the incident gathered from sources such as workers involved, witnesses, equipment on the scene and documents such as inspection reports and maintenance logs. In most cases, a catastrophic incident was not a single event but rather a chain of events. It is important to understand exactly what happened by digging into the fine details leading up to the event. What were the operating conditions? Exact weather conditions? What process were workers performing at the time of the incident? It is vital to interview site 80 WWW.LAWYER-MONTHLY.COM | APR 2022 EXPERT WITNESS personnel to gain observations, opinions, and insights into workplace norms, workplace culture and generally accepted behaviours. Site investigation and evidence recovery takes a significant amount of time as evidence is commonly buried or damaged by fire. Quite often, a tiny fracture of something in pile of debris is very telling evidence. Step 4 – Analyse Data to Determine Incident Root Cause. After data and evidence is collected, it must be analysed to help find the root cause of the incident. The IFO Group has a climate-controlled inspection laboratory and workshop where we facilitate the inspection and documentation of collected evidence and artefacts from the incident. Process analysis and laboratory review are crucial and commonly involve modelling and simulation done through the input of variables – what happened before the accident, during, and after to help fully understand the sequence of events. It is important to remember that finding the The key to incident prevention is the establishment of top-down safety precedence.

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