Four day accident investigation Course UK syllabus

Four day Accident Investigation and Evidence Gathering Programme

Day one

This course was developed under the umbrella of English Law.  It must be remembered that industrial investigators are not prosecutors, do not deal with suspects, do not interrogate and in effect are carrying out a scientific data collection and analysis process.  The programme below is flexible as some organisations might wish to concentrate on specific areas of the syllabus.

Terms of Reference (TOR)

What TOR does your organisation follow.  Explicit and implied TOR in AI

The effect of working with organisations who use either different TOR or have failed to establish a set of their own

Aims:
To develop cognisance in relation to:
Organisational responsibilities
The TOR of other stake holders

The TOR of prosecution authorities

The need to develop cognisance within Corporate executive team in relation to stated TOR

How TOR affect process and legal status

Conflict between TOR in different organisations

Understanding JV TOR issues

Objectives:
To ensure that investigators identify organisation TOR within their organisation and other stake holders involved in the investigation

The legal, commercial and moral arguments for carrying out investigations.

Commercial – the true costs of accidents and the benefits of utilising a structured investigation system to evaluate areas of actual and potential failure within the Safety Management System.

Costing loss events
Identifying costs in terms of turnover
Identifying costs in terms of reputation impact
Identifying costs in terms of impact on project budget
A method of quickly examining the costs of accidents
understanding the issues within supply chains
Understanding loss in terms of cost to wider business when considering government organisations such as Police, Fire Service and Local Government

Aims:
To raise cognisance in relation to:

The impact of loss on turnover and budget
The associated issues with subcontractors
The issues surrounding public body and loss cost
The methodology of assessing loss
Identifying organisational cost standards

Objectives:
To ensure that investigators utilise a costing process within their report

Moral – the failure in the past of moral reasoning as a vector for inducing change and the current perspective linking morality to public perception and image.  The current drive towards ethical practices and the link to the corporate governance of loss

Aims:
To raise cognisance in relation to:

The link between reputation and loss
The need to identify repetitional motivators within the organisation

Legal – A review of the issues surrounding evidence gathering during investigations.  Some basic issues

Are you allowed to investigate?
The restrictions associated with investigations and section 69 (9) of PACE
Witnesses and Suspects
The positionality of the discipline process (Engal)
What personal and corporate exposure is there
What are the local powers of the official bodies tasked with carrying out investigations
Notice of Powers and Rights and entry to private property by authorities
Ownership of documents and exhibits before the fact
Ownership of documents and exhibits after the fact
Civil issues
PACE issues Cognisance of issues surrounding interviews under caution and witnesses

Aims:
To develop cognisance in relation to:

Identifying the legal system that the investigation is working within
Understanding the the ‘rule’ of that system
Understanding the ‘rules’ controlling legal advisors in relation to that part of the law
Appreciation of the difference between PACE interviews and witness interviews.
The appreciation of the reasoning behind identifying Competent Criminal Legal Advice
The issues surrounding Entry Search Seizure and Disclosure
The issues surrounding third party sites
The issues surrounding controlling minds and PACE interviews
The issues surrounding Cautioning and suspects

Objectives:
To ensure that lead investigators (LI's) ensure that the investigation is carried out at the correct legal level and that the basic rules of law associated with the process are followed.

Organisational ‘Buy-in’

The importance of achieving acceptance from the organisation of the need for in depth investigations if corporate development is to be achieved

Understanding Causation at a corporate level

Understanding Corporate Governance of the working environment

Aims:
To develop cognisance in relation to:

The link between organisation development and good data
Issues surrounding epistemology and ontological positioning and how this affects evolution within the organisation
Recognition in personal, organisational and stake holder ontological positioning in relation to the appetite to carryout full causal analysis
Understanding Causation

Objectives:
Ensure that senior executives are aware on the issues within the aims

Organisational Failure areas and the extended event failure model

Changing the positionality of events from individual incidents to symptoms of wider issues

An examination of the ‘extended event failure model’ its terminology and processes

The blame cycle and organisational groupthink

An examination of a modern accident causal diagram with linkage to auditing and KPI setting and extending the BRF model

The role of decision makers in relation to accident causation and the setting of basic risk factors DMF analysis – the need for corporate trend analysis and introspective examination.

Aims:
To develop cognisance in relation to:

The modern interpretation of the vocabulary associated with AI
The fact that old fashioned tree models simply do not function in the modern context
The issues surrounding Psychological Precursors and that they are symptoms of the environment where individuals operate.
The issues surrounding the identification of BRFs and that these are organisational failure areas
The relationship between BRF existence and guilty knowledge within the organisation
The link between DMFs and BRFs and ultimately what the term underlying causation refers to.
The need for facilitated discussion in the DMF identification process
The fact that each organisational culture will have its own set of BRFs and DMFs
The issues associated with stopping investigations at the BRF stage and repeat events

Objectives:
Investigators will assess BRF’s DMFs and psychological precursors in a holistic fashion and be able to argue why facilitated discussion is essential if an organisation is to evolve
Investigators will use the model to examine events and provide evidenced assessments

Cyclic process and the use of data to provide executive management teams with information to effect change.

Primary, secondary coding of organisational failure area data
Tertiary coding of EEC and the development of ethical positionality within the organisation
The use of facilitated discussions
The issues associated with the corporate governance of loss
The role of the executive board
The positionality of symptomatic events
The use of coded epistemic data
The identification of how cyclic process is achieved.
Educational issues relating to data analysis and collection.

Action to be taken at the scene.

An analysis of a flow diagram identifying the process of investigation.  Based on an agreed UK model showing considered best practice; developed by ACPO, ACPOS, HSE, IOSH and Kinaston this section of the course is intended to provide organisations with the information needed to develop a cohesive investigation plan.  The process examines three levels of loss events.  Although the flow diagrams are UK specific documents, it is good practice to consider the action that authorities may take and to develop a strategic plan that does not cause conflict within the legal system where one is operating.

Near hits (Non-conformities)

Accidents where the authorities will not be attending

Fatal and serious events where the authorities may be attending

Aims:
To develop cognisance in relation to:

To the issues surrounding scene management at all levels of events
To the issues surrounding working with the authorities
To the issues with secondary scenes / exhibit sources
the role of the coroner’s officer

Objectives:
To establish a coherent AI system that is compliant in relation to the level of investigation, TOR and the locus of the process

Homework

Homework consists of examining the nature of reports and the direction of flow linking in to identifying organisational evolutionary positioning
 

 

​

Day two

Information sources

An examination of the key sources of data and the correct use of associated terminology

Different types of evidence; Real, Documentary, Restricted information, Journalistic material, special procedure, legal privilege, expert evidence reports

The importance of not discounting information, hearsay and even gossip and that data collection is different from prosecution evidence gathering

Fact and opinion

Where to find evidence

The role of technical experts and tools such as fault tree analysis, FTMA etc. within the investigation procedure

Witnesses - the definition and who this can include

Discussion in relation to research subjects rather than witnesses

Aims:
To develop cognisance in relation to:

the different types of data available and the terminology used in the legal process
to the rules associated with access and distribution of different types of data
not to ignore the value of anecdotal data and the probative value of trended results
the failure in the past of following the lead of prosecutors in the belief that this type of investigation is fit for purpose when examining underlying causation
the limits of FTA etc
the concept of witness and who it includes

Objectives:
To ensure that LI use the correct terminology and are not confused when other do
To ensure that LI understand the law in association with dissemination of different types of data
To ensure that LI will look at a wide range of data sources

Interview preparation using a ‘themed’ approach

Why a themed approach should be used

How to conduct a themed interview

Introduction to a set of themes

Aims:
To develop cognisance in relation to:

The concept of interview structure
The need for obtaining data other than simply from event
The issues surrounding developing sets of open questions from themes
The use of the generic set of themes as a basic set of criteria

Objectives:
LI will use themes as a methodology thus structuring their interviews and data collection
the development and use of theme maps
LI will use themes as a basis for developing a set of open questions

Questioning of witnesses

Open and closed questions
Closed ended questions
The issues surrounding the use of closed ended questions in reporting systems
Prejudicial questions
Regressive and progressive questions
Perceptual confusions and their effects on the quality and effectiveness of investigations

Aims:
To develop cognisance in relation to:

Issues surrounding question types
Issues surrounding Gestalt formation
Issues surrounding Cognitive recall
Issues surrounding leading of witnesses
Weakness of question lists
The problems associated with witnesses writing their own statements
Associated risks with the use of RP questioning techniques
Issues surrounding interviewers perceptions, closedowns, double barrelled questioning
The use of Memoing to control the development of interviewer bias

Closed questioning exercise

Aims:
To develop cognisance in relation to:

To experience issues surrounding perceptual confusions
To experience issues surrounding the ontology of the interviewer when closed questions are used

Objectives:
LI will be aware of the issues when using closed questions

Counselling and trauma issues

Aims:
To develop cognisance in relation to:

issues associated with CPTSD and the LI role

Objectives:
LI’s will at least consider the need for personal counselling

Room setting and witness considerations for interview

Aims:
To develop cognisance in relation to:

awareness of the issues associated with the anxiety ladder and how to take measures to calm witnesses

Objectives:
LI’s will consider the interview venue and where possible will provide a positive environment for interview


Intimidation – the failure of panel interviews and the past effects on unaware organisations

Aims:
To develop cognisance in relation to:

awareness of the issues surrounding panel interviews and the difference between interrogations and witness data collection

First recall exercise

Delegates listen to a number of first recalls to hear certain issues

Aims:
To develop cognisance in relation to:

length of first recall
non-witness issues
black humour
coaching of witnesses
emotional issues from witnesses

Note taking skills

An examination of the best practice in note taking taking two different approaches of spider diagrams and bullet points

Aims:
To develop cognisance in relation to:

the issues surrounding different forms of note taking

Objectives:
LI to develop a note taking methodology that works effectively for themselves

Interviewing exercise and assessment (Role Play)

A major part of the course introducing an accident that forms the basis of the analytical processes carried out in the subsequent days

Aims:
To develop cognisance in relation to:

the use of open questions
the use of themes
note taking
Listening to other interviewers questioning styles
Critically assessing questions
Examining questions before they are asked
Listening to answers
Examining answers

Objectives:
LI’s will utilise open and themed questions in order to obtain data from witnesses

Evening reading and discussion sheets


 

Day three

Introduction of statements

Why bother writing up interview notes?  The use of statement writing as a means of analysis of the completeness of data
Disclosure of information
Statement issues
Sharing of information
The link to discipline and no disclosure of information
Ownership of information
The legal requirement to use statements
Issues surrounding coaching
The corporate Manslaughter act 2007
The sentencing guidelines

Good practice in relation to writing up interview notes

Statement taking conventions
Statement taking exercise
Frequently asked questions in relation to statements – Issues for organisations

Aims:
To develop cognisance in relation to:

the use of Sec 9 papers
the use of exhibit labels
the issues surrounding sec 9 captions
issues associated with full names and ages of witnesses
issues surrounding statement taking conventions
disclosure of statements
statement ownership
witness ownership
storage
alterations
solicitor coaching
perverting the course of justice
good data collection
issues surrounding completeness of statements and questioning being realised at the writing up stage
issues surrounding signing and correction
The maintenance of the integrity of the data collection system and the importance of not tying it in to the discipline process
Legal issues surrounding discipline and data collection during criminal investigations.
R V Momodou and issues surrounding coaching
Issues surrounding coaching interviewers to take specific defence related statements
Issues surrounding the advice to barristers regarding coaching and witness training

Objectives:
LI’s will produce good data from the statement taking process following the basis of ‘grounded theory’ and empirical legal qualitative data collection
LI’s statements will provide a legally compliant and academically sound data source for further analysis

BRF analysis exercise – key issues: Corporate analysis and the use of data to identify trends

The Blame cycle

Identifying the blame cycle and its elements (link to day 1)
 
Organisational Failure Categories / Basic Risk Factors (BRF’s) Primary/secondary and tertiary coding

Coding VAAE

Link between Developing VAAE and Violations

The cyclic investigative system

Examination of the OFA’s and identification with real life issues.

Identification of Organisational failure areas

Identification of critical themes

Identification of VAAE

Epistemic opinion and credibility through secondary coding

The use of OFA’s as a means to audit

Comparing sectors and performance using OFA’s and critical themes

Aims:
To develop cognisance in relation to:

To understand the simple process of BRF identification
To understand the coding process linked to grounded theory
To understand the VAAE issues
To understand the link between VAAE control and violation
To understand the importance of the data control system
To understand the need for facilitated discussion training at exec level
To understand the need for anonminity
Different BRF recording systems
Issues with electronic systems
To understand the concept of each organisation having their own set of BRF’s

Objectives:
LI’s will develop an awareness of the BRF categories and start examining weaknesses during the interviewing stage of the process, enabling more in depth data collection to assist with triangulation of grounded hypothesis

File preparation

The preparation of a correctly ordered and formatted investigation file; what is the minimum of information required and why is it needed

Final report writing

The distinction between recommendations for substandard acts and causal failure

The use of ‘human failure’, ‘human belief’ charts and BRF failure charts to demonstrate where areas of organisational concern exist and the identification of a way forward to remedy issues and develop cultural change.

The direction of the report to follow chronology of process

Aims:
To develop cognisance in relation to:

To recognise the need for policy decision forms
To recognise the use of loose leaf witness and exhibit list forms
To understand the nature of the forms in relation to their role
To recognise that SOE can not be destroyed or altered and that the notes are discoverable and disclosable
To understand to minimum elements of the file process
To recognise the limits of computerised systems
To recognise the issues associated with PNB and desk diaries
To identify with writing reports chronologically
to fully understand the trending process and the importance of coding information

Objectives:
LI’s will be able to prepare a complete file in relation to all types of loss events

 

​

Day Four

Human Failure and Belief

This is an involved an highly linked day where delegates are asked to carryout a number of practical exercises aimed at recognising the processes of error violation and belief.

Human error

Human violation

Human Belief issues and the effects on substandard acts

Automaton functioning

Learning Issues and their impact on event causation  

Human Failure exercise

Human belief exercise

Aims:
To develop cognisance in relation:

to being able to recognise error
to understanding some of the limits of error
to being able to question simultaneous error
To identify with the concept of automaton functioning and error
To appreciate the issues surrounding the hypothesis of primary / secondary and tertiary automaton functioning
To understand the issues surrounding aural and ‘visual’ blindness and error
to identify with the different definitions of error and that it is an internal function
to being able to recognise violation
to being aware of the three key types of violation
to being aware of violation at all levels of an organisations
to being able to identify violation in relation to the overriding caveat
to being able to recognise automaton functioning and semi-automaton functioning
to being able to identify automaton functioning
to being aware of the propensity for LI’s to read their own expectations into the actions of others in the process.
of human belief
of human belief and managerial decision making
to human belief and the link with error enforcing conditions
to organisational (human) belief
to how to represent human failure and belief

Objectives:
LI’s will be able to examine human failure using a chart system
LI’s will be able to identify human belief
LI’s will utilise system to examine the whole event
LI’s will appreciate that the HF chart is not a Blame Chart

Empirical legal research methodology and the use of grounded theory

The use of GT methodology in identifying underlying causation

Issues surrounding old fashioned tree style list and the switch to GT methodology

Aims:
To develop cognisance in relation to:

the academic processes involved in accident investigation
the importance of being able to justify the processes used from an academic perspective
the terminology used to describe the academic process
The understanding of GT as an academic process suited to looking at empirical qualifiable data

Objectives:
LI’s will use the process with confidence as they understand the foundations it rests upon

Final BRF analysis exercise

Aims:
To develop cognisance in relation:

To how two different organisational cultures have different BRF failures that cause them to function in a sub-standard manner
to raise awareness of total supply chain control
to raise awareness of issues with JV’s

Objectives:
LI’s will look at each organisational culture against separate BRF failure lists

Recommendations

An outline of current best practice describing failure from BRF downwards, rather than upwards from the event

Aims:
To develop cognisance in relation:
The weaknesses of the old fashioned tree style systems in that they do not ID UC
The arguments for using downstream report writing commencing at organisational failures


Close of Course