EtttcttlEUR
Wo rkplace I ncident Site
lnvestigation
By lr. TajulAritfin Mohamed Nori
Factories and Machinery lnspector
lnvestigation and Prosecution Section
Department of Occupational Safety and Health Selangor
B & 6orkplace lncidents may interrupt
U&p production activities or business
Y Y operations. The term is related to events
or situations occurring from any course of work
which affects workers or public welfare, health and
safety. This may or may not involve injuries, illness,
or in worse case scenarios, fatalities. ln some
cases, incidents may result in property damage.
Victims may undergo serious trauma which might
result in the loss of a limb, for example, which
would cause him/her to cease operational activity
either temporarily or permanently.
There are numerous reasons why an
investigation should be carried out. Law
enforcement officers might need to determine
whether there was any violation of the law that
led to the incident and to decide whether any
punitive actions should be imposed on the
involved party. Some might try to benefit from
deficiencies inherent in the occupational safety
and health management system that caused the
incident. Human resource managers might need
to process compensation claims arising from the
incident. Most importantly, the main objective
of investigation is to ensure the causes of an
incident can be identified and the right corrective
actions or improvements can be made to ensure
that similar incidents will not be repeated.
VOL 76 OCTOBER-DECEMBER 2O 18
An effective and thorough investigation
should be carried out as soon as possible to find
the underlying and root causes of the incident. A
structured investigation process is important to
ensure all elements that lead to an incident can
be identified before any corrective action is taken.
Small or large, occurrences of dangerous incidents
are opportunities to avoid any recurrence. Reactive
investigations of each incident will demonstrate
organisational commitment to a safe and healthful
work environment.
lnvestigations may be conducted by a single
person or a team. lt is the function of an established
Safety and Health Committee to investigate an
incident as mandated by Occupational Safety
and Health Act (OSHA) L994.ln many workplaces
the investigating team is known as the incident
response team or emergency response team (ERT)
and is composed of members trained to respond
to an incident. The person responsible for carrying
out an investigation maybe a regulator, operations
manager, safety manager, safety and health
officer, supervisor at the workplace, or possibly an
ad hoc person who is directed to determine the
cause of the incident. Some fundamental guidance
for investigators is essential and the details set
out in this article will guide any responsible person
when carrying out a workplace investigation.

INCIDENT SITS INVESTIGATIOTII STRATEGY
f,eeponee to an lncldant
lnvestigations must be conducted without
undue delay from the time a notification of an
incident is received. An investigator should
respond immediately and reach the scene as
soon as possible. The investigation process will
become more difficult as a result of changes
or disturbances at the scene due to a delay in
initiating the investigation. Factors that may
affect the incident site include search and
rescue operations, weather, intentional removal
of evidence to cover up the chain of events,
disappearance of volatile chemicals or gases
and perhaps an unintended clean up might have
tampered with the evidence.
lncidents should immediately be reported to
the authorities to ensure that there is no violation
of any laws arising from a disturbance at the
scene. For example, in the event of an incident
involving a fatality or serious injury, it should be
immediately reported to the Fire and Rescue
Department for rescue purposes. The police
must also be informed to ensure that any criminal
Catastrophic Crane lncident
activity directed at the victims can be investigated.
ln addition, the department responsible for the
safety and health of workers must be informed.
It is the statutory duty of an employer at any
workplace, upon the occurrence of an incident
to notify the Department of Occupational Safety
and Health (DOSH) of an incident involving an
employee under the OSHA Act 1994. Section
32 of OSHA 1994 has outlined that any incident
occurring at work should be reported to the
nearest DOSH office. These requirements are
also set out in the Occupational Safety and Health
regulations, Notification of lncidents, Hazardous
Events, Occupational Poisoning and Occupational
Diseases 2OO4 (NADOPOD). Hence, it is important
for investigators to have a good understanding of
relevant legislation related to workplace incidents.
Pre-vlelt afid plannln$ af Blte Investlgatlan
Except for a regulator or a law enforcement officer,
custody of the scene must be released by the
authorities or any related agency before anyone
may enter an incident site. Other exceptions
tolerated by law are those rescuing victims,
maintaining public access, or preventing further
ErncruEUR
damage to property or environment. lnvestigators
or teams should identify the person-in-charge at
the incident site and contact him/her prior to a
site visit. They should briefly explain the reason
why they are conducting an investigation. To
improve the effectiveness of the investigation,
the managers or victim's colleagues should be
involved during the inquiry process.
Safety precautions before any investigation
should be taken to establish if there is any
residual danger at the site, the methods to access
the area, the level of risk at the site, whether
control measures should be considered during
the process and whether any personal protective
equipment is required.
Create $ome Hypotheses
The initial hypothesis is important in any incident
investigation to ensure that all possible causes
VOL 76 OCTOBER-DECEMBER 2018
Collection of Evidence
are properly considered. Possible hypotheses
should be tested throughout the investigation
process. The most possible hypothesis is the one
that matches most of the facts and evidence and
is likely to lead to the root cause of the incident.
Sometimes challenges are faced by investigators
when conducting investigations in areas that they
are notfamiliar with or it is beyond their knowledge.
This makes it difficult for investigators to form
valid hypotheses of the accident. To overcome
this issue, investigators should review documents
specifically related to workplace activities such
as: Job Safety Analysis, Hazard and Operability
Study (HAZOP), material safety data sheets, risk
assessment reports, safe operation procedures,
permits-to-work, or any other related workplace
checklist that can help the investigators narrow
down possible deficiencies in the safe working
system that led to the accident.

Barricade Area of lncident to Avoid Tempering of
Evidences
Ch r o n ol o gy e sta b I I sh m e nt
A good investigation process should establish a
logical chronology. lncidents do not happen all of
a sudden without any timeline. There should be
some historic sequence of events that led to the
adverse mishap. The chronology of an incident
can be established by reviewing maintenance
records and other documents such as operator
daily checklists, etc. lnterviewing witnesses, the
victim's colleagues and his/her supervisor are also
essential. Once a clear chronology is established,
it will help investigators gather necessary evidence
based on the sequence of events throughout the
i nvestigation process.
F act-fl ndtng an d Docu me ntatl a n
lndividual investigators or teams should be aware
of any abnormalities at the incident site or its
aftermath. Apart from that, good observation skills
will help to establish factual information. When
seeking the facts of the case, investigators should
master the techniques of fact-finding based on
the evidence that exists at the scene and not from
hearsay information. Any abnormal conditions
such as fractured components, broken parts,
friction effects, scratches and structural changes
may lead to firm evidence as to how and why the
incident took place.
Evidence can be obtained from either physical
evidence, documentation evidence or information
gathered from witness statements. All facts and
evidence should be recorded via photographs,
notes, sketches, or witness testimonies.
Determining appropriate evidence will be useful
and may add credence to the investigation
process and support the facts of the incident.
Some guidance on extracting the facts behind
an incident will be further elaborated later in the
article.
Prlor ta Leavlngthe $tte
Some complex cases require a series of follow-
up investigations. lf there is any need to carry out
further investigations, the scene must be secured
from any possible changes. Disturbance of the
scene must be avoided by restricting access.
Proper barricades must be erected around the
perimeter of the incident site and prohibition
signages put up. lnvestigators must make sure
that no more information can be collected from
the scene before it is released for rectification
work. When the investigator releases the incident
site, he must make sure the place is safe, before
any rectification work can be carried out.
EXTRACTION OF FACTS FROM THE PLACE
OF INCIDENT
and Labelllng of Evldence
Taggtlttg,
Before any photos are captured or evidence
retrieved from the site, the objects must be tagged
or labelled. Tagging and labelling are important
to add credibility to facts and ensure they can
easily be identified for future reference. With
this technique, investigators can systematically
organise the facts of the case.
Photography
Photography is the most common technique for
documenting facts at the site of an incident.
Adequate knowledge of basic photography
techniques such as depth of field, light control
ErrucruEUR
techniques, shutter speed, etc. is very important
to ensure that all the photos captured during site
investigation are of good quality - non-blurry
images, proper brightness and sharpness - to
show details of the scene.
Proper planning and selecting the right
subjects to capture rather than random shots
are essential to avoid missing any important
facts. Marking photos in chronological order and
right sequencing will ease analysis and report
writing and will be useful if it comes to a court
proceeding.
As many photos on a single subject should be
taken as possible even though not all the photos
will be used in report writing or court proceedings.
Photos should be captured from multiple angles
and ranges (Focus, medium and far range). lt is
important to note that all objects must be tagged
or labelled, as highlighted earlier, before the
photos are taken.
Skefchln$
Sketching is essential during incident site
investigations when there are limitations
in recording the place of an incident using
photographic techniques. When describing the
scene thoroughly, it is useful to complement with
some sketches. For example, when investigators
want to describe the area of a scene i.e. a room, a
single sketch of the layout plan is enough, rather
than a series of photos. Any observations from
the scene that cannot be photographed should
be sketched and these include measurements,
dimensions of a building, length of a structure
etc.
Sketches can help investi$ators correlate
photos taken and the original location of the
evidence. All sketches must be signed by the
person who drew them, including detailed
information such as the date and time as well
as the place of the incident for future reference.
Sketches of incidents do not require a high level
of drawing skills as simple symbols can be used to
explain something. References such as compass
directions and permanent objects should be
included in the sketches. Examples of permanent
objects are building walls, trees or permanent
structures, for the purpose of determining the
position of evidence, subject, or victim during a
re-visit to the scene.
VOL 76 OCTOBER-DECENiIBER 2018
Evldence Mana$ement and Gfialn of Custody
Evidence management is a critical element in
explaining facts related to an incident. Good
evidence management requires traceability of the
evidence from its origin and substantiation of its
authenticity. Any evidence obtained should correlate
with relevant incident facts. The chain of custody
should be established in chronological and logical
order to ensure there is no challenge or question
to the evidence. This is especlally important, if an
incident leads to a criminal trial or civil litigation.
Any evidence to be admissible in a court of law has
to adhere to the provisions set out in the Evidence
Act 1950. Crime-related evidence must follow the
provisions of the Criminal Procedure Code (Act 593)
as they apply to the incident.
The correct techniques to extract the evidence
from a scene should be selected. This is to avoid
tampering with the evidence and preserving it for
any required laboratory tests or if it is to be used
in a court proceeding. lnvestigators or teams need
to know the kind of evidence they have to take,
the sampling method, packaging requirements,
and how it should be stored. Wrong sampling,
packaging and storing techniques can cause the
selected evidence to be affected. For example, in
the sampling of volatile liquid chemical, choosing
the right equipment for sampling should be
identified to prevent the evidence from vaporising.
No evidence can be collected from the site before
tagging or labelling, sketching, and photography
have been completed and recorded.
Wltnesses
Witness interviews are a process of finding the
cause of the accident and not establishing fault.
Communications between the investigator and
the witness must be professional and ethical.
Harsh questions will mislead the interview
process and the witness will begin to conceal
important facts in order to avoid being blamed,
even if they are totally innocent. Questions asked
professionally and neutrally, that do not look for
fault, will make the witnesses more co-operative
in telling the truth. The right choice of questions
should be selected during the interview process.
lnvestigators should always remember that
when interviewing a witness, they should avoid
leading questions. Leading questions may plant
some thoughts which do not originally come from
the witness but from the person
who is asking the questions. lf
witnesses are shadowed by the
wrong presumption, then the
whole witness interview process
will be misleading. lnvestigators
should always ask opened-ended
questions.
All the witnesses involved
should be identified as soon as the
first incident notification is received.
Witness details should be recorded
such as full name, identification
card, phone number, and address
for the purpose of re-contacting for Crawler Crane Toppled Incident in Construction Site
an interview if further information
is needed. The witness's testimony
is crucial while the incident is still fresh in the techn iq ues of cond ucti ng effective investigations.
memory, before they forget, or their evidence is Small or large scale incidents are opportunities
distorted by discussion with others. Eyewitness that should not be overlooked by an investigator
statements are very important to ensure the as they provide opportunities to acquire the right
getting at the facts from
accuracy of the fact. lt is important to note that techniques and skills in
any statement recorded from a witness should an incident and building an understanding of
be valid observations and not just assumptions. examples of defective risk management in the
ln some cases, when there is no eyewitness, a workplace. lncident investigation is an important
witness who knows about the process or activity element in risk management as well as effective
related to the incident should be interviewed and occupational safety and health management.
other alternative sources like CCTV records (if More severe conditions may arise in the future if
available) used to identify credential evidence. the cause of an incident is not resolved properly.
lmmediate action to call for an investigation and
Report Wrtiln$, and lncldent Anatysls taking the necessary corrective actions, will result
Once investigations are complete, the investigator in a preventive workplace culture. r
should immediately prepare an incident report
REFERENCE
and carry out an incident analysis based on facts
extracted from the place of incident (photographs, lnvestigation of Occupational accidents and
sketches, witness statements and documents) Diseases: A Practical Guide for Labour lnspectors,
to determine the cause of the incident either lnternational Labour Organisation.
in parallel with the original hypothesis or if new Investigating Accidents and lncidents: A workbook
findings have been established, to proceed or for employers, unions, safety representatives and
stop further investigation. This is to ensure the safety professionals, Health and Safety Executive
investigation has been satisfactorily completed uK,2004.
and adequate evidence has been gathered to
www.cri me-scene-i nvestigator. net
discover the root cause of incident.
The right way to tag and label evidence - www.
superiorbag.com
GOilCLUSDt{ Occupational Safety and Health Act 1994
(Act 514)
Good investigative skills cannot be obtained only
by attending training programmes; it requires Evidence Act 1950
lots of practice before someone can master the Criminal Procedure Code (Act 593)