When the Worst

Case Happens

Best Practices for Planning

for Successful Major Incident
Investigation Outcomes
 How do you define a Major Incident?

• Fatality
• Major Bodily Injury
• Reportable Environmental Incident
• Fire or Explosion
• Reputational Risk Incident
• Security Incident
• Significant Property Damage
• Major Process Safety Incident with
Loss of Primary Containment
• High Risk “Near Miss”
• Incidents Involving Contractors www.ifogroup.com
 Who are you going to call?

• Executive Management
• Corporate Risk Management
• Insurance Company
• Legal Department / Outside Counsel
• Public Relations / Corporate
Communications
• HSE Department
• Regulatory Authorities (CSB, OSHA,
EPA)
• Crisis Management Team
• Third Party Incident Investigation
Consultants and Contractors www.ifogroup.com
 The First 24 Hours

• Notify the investigation team and outside

counsel and get them onsite as quickly as
possible.
• Identify and secure any potential evidence
that isn’t physically present within the primary
perimeter.
• Begin scene documentation with video,
photography, and LIDAR scanning.
• Identify and quarantine witnesses.
• The investigation cannot interfere with the
emergency response….but….the sooner it
starts the more likely that the investigators
will be able to identify and preserve critical
evidence that could be otherwise lost. www.ifogroup.com
 Investigation Scope

• Will an effort be made to manage the

investigation as privileged work
product?
• Investigation Methodology
• Root Cause
• Contributing Cause(s)
• Subrogation Considerations
• Scope of Investigation
• Unit
• Site
• Business Unit
• Corporate wide www.ifogroup.com
 Planning

With due consideration for the scope

of the investigation it is key to
estimate and plan the following:
• Schedule
• Budget
• Staffing
• Time required on scene
• Time until the site is released back
to operations or site owner.
• Lab backlog and processing time.
• Time to draft report
• Time to final report www.ifogroup.com
 Investigation Command

• Who is in charge and

authorized to make timely
decisions?
• When will the incident fully
transition from emergency
response to investigation and
recovery?
• Include the investigation team
in Unified Command

www.ifogroup.com
 Investigation Team
• Successful management of major
investigations requires significant
project management experience
with investigations, a great deal of
tact and diplomacy, endless
patience, and willingness to go the
distance all the way to
investigation closure.
• Ensure that the experts assigned
will be viewed as credible
(internally and externally).
• Identify and avoid conflicts of
interest.
• Find the right experts for the
problem. www.ifogroup.com
 Safety

• Is it safe for investigators to begin

their work and have all major
hazards been identified?
• Is there any risk of a secondary
incident?
• Is the correct PPE on site and
readily available?
• Is assigning standby medical or
rescue resources appropriate?
• Achieve positive control of
energy sources.
• The scene should not be a
“tourist attraction”! www.ifogroup.com
 Evidence and Scene Management

• Evidence Collection and

Management Protocols
• Scene Access Control
• Designated Evidence Custodian
• Evidence and Scene Access Logs
• Chain of Custody considerations
• Temporary on-site storage of
evidence
• Long term secure evidence
storage
• Take care to avoid future
spoliation claims! www.ifogroup.com
 Information Management

• Confidential vs. Public Information.

• “Need to know” and NDA’s.
• Have an investigation communications
plan (don’t be cannon fodder for the
news media).
• Communicate early and often.
• Don’t neglect internal communications!
• Make sure the person managing
communications has the latest
information and knows what can be
shared. Highly recommend retaining
an experienced public relations firm.
• No speculation!!
www.ifogroup.com
 Playing Well With Others

• Pooling of resources.
• Working with other investigators,
agencies, and attorneys.
• Coordination of messaging.
• Recognition that everyone has a
job to do.
• You will very likely need the
assistance and cooperation of
other parties involved in the
investigation.
• Assign someone to the
investigation team as a Liaison
Officer to the other parties. www.ifogroup.com
 Logistics

• Contracts and Procurement

• Take care of the basic human
needs quickly.
- Sleeping quarters
- Food and water
- Basic hygiene
- Laundry
• Secure office space for the
investigation team and counsel.
• Evidence storage (on and off site)
• Identify other needed resources
(equipment, people, expertise) www.ifogroup.com
 People First

• Be observant and ensure that

people assigned to the
investigation team are coping
with the stress of their work in a
healthy manner.
• Actively manage fatigue risks.
• Help the team members stay in
contact with their family and
friends while the investigation is
ongoing.
• Have a backup plan in case a
critical member of the team has
to be replaced. www.ifogroup.com
 Resuming “Normal” Operations

• Start from the beginning of the

investigation with a definition of what
“normal” operations should look like
post incident.
• Keep the focus squarely on
determining the root cause and
contributing cause(s) but remember
that the incident consequences are
far reaching for employees,
contractors, the public, shareholders,
customers, etc.
• Facilitating the return to normal
operations should be a key
consideration for the investigation
team. www.ifogroup.com
 Investigation Closure

• Termination of major investigation

activities.
• Investigation team members and
support staff released.
• Securely archive and store
investigation documents and
related media.
• Secure storage of critical physical
evidence that may be needed for
future legal proceedings.
• Final opportunity to ensure that
you have dotted every “i” and
crossed every “t”. www.ifogroup.com
 Investigation “Hot Wash”

• Conducted within 30 days

after completion of the final
report.
• Identification of what went
well during the
investigation…..and what
didn’t go so well.
• Invite the stakeholders.
• Can help provide the
investigators and
stakeholders with closure.

www.ifogroup.com
Investigation Costs

• Everyone’s “favorite” topic

• My “favorite” answer - “It depends”
• In general, plan on 1-2% of the overall
value of a large loss and 3-5% of a small
loss as a good rule of thumb for
investigation and legal costs. Heavy or
specialized demolition requirements at the
site may add another 2-5%.
• Investigation, demolition, and
environmental mitigation expenses may
be recoverable through insurance.

www.ifogroup.com
 Investigation Procedure or Plan

• Table top planning for major incident

investigations.
• Consider integrating Incident
Investigation Plans into Emergency
Response Plans.
• You can’t anticipate every scenario but
an effort should be made to consider
how the organization should respond
to a given incident, i.e. fire, explosion,
occupational fatality, workplace
violence, major contractor injuries, etc.
• Talk to your corporate counsel and
include them in your planning!!
www.ifogroup.com
Questions

info@ifogroup.com

dfretwell@ifogroup.com

bdunagan@ifogroup.com

www.ifogroup.com