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Fast Response Accident
Investigation
Written By: R. Craig Jerner, Ph.D., PE
First Published February 1993, in "Risk Management Magazine"
Accidents always occur at the most
inopportune time! Regardless of the accident cause, it is only a matter of time before the company, their insurer, attorneys,
or professional accident investigators will be trying to sort out the facts in
order to determine the true cause of the
accident and to assess financial damages.
Throughout this process, accident investigators continually hear one statement from risk managers, insurers, defendants' and plaintiffs'
attorneys alike: "Just tell me what happened, and tell me as soon as possible." Such a statement is not surprising.
Companies, their insurers and all attorneys want an early and accurate
picture of how the accident occurred. Factual evidence can be obtained through an immediate, meticulous
accident investigation conducted by experienced experts who analyze the accident scene and accident
evidence to determine causation and to preserve all accident evidence.
However, recent court mandated procedures dictate
more evidence control (evidence
spoliation) and joint
destructive testing.
Risk managers often do not take the appropriate steps to secure and protect accident evidence available at the accident
scene. Consequently, accident-related evidence, which often is the only proof of how the accident actually occurred, is often lost, damaged or altered diminishing its usefulness
in case exposure evaluation,
litigation or settlement negotiations. To avoid this, risk managers and attorneys must implement procedures to ensure that a rapid, competent, on-site accident investigation is conducted that secures the site
and preserves important physical accident evidence. This type of approach, known as a fast response accident investigation, will optimize the investigation's results and preserve key evidence for later
evaluation. Fast response accident investigation can also result in the reduced litigation and settlement costs.
ACCIDENT INVESTIGATION
An accident can be defined as "an unexpected/undesirable event that occurs at a specific place in
time". Considering the vast amount of litigation that results from accidents, perhaps it would be more appropriate to add
to this definition the statement "which will
often lead to
lengthy, frustrating and costly litigation." If an accident occurs, and someone is injured and/or there is property damage, a lawsuit will most surely result. In light of the high costs of litigation, accident
investigators will analyze all available evidence associated with the accident to determine
the accident cause.
What is needed is a "snapshot" of the forces, events, positions and actions of the people, products and equipment involved that led to
the accident. If accident investigators were present at the time of the incident and had a sufficient number of cameras, good lighting and the proper viewing angle or angles, they could quite possibly record a
rapid sequence of photographs that would document the event perfectly and completely. However, more often than not, accident investigators may not even have good "just after it happened" photographs,
and possibly, no scene photographs whatsoever. In addition, any physical objects associated with the accident, whether they are actual evidence or extraneous materials, were likely to have been altered by
people who do not realize that tampering with such objects can greatly hamper the accident
root cause investigation.
Unfortunately, examples of lost, mishandled and degraded evidence are numerous. In my own experience, after a high pressure natural gas
well exploded on federal land, a forest ranger picked up a small oilfield tubing coupling left from the explosion, and took it home as a souvenir. As it turned out, the coupling joined two pieces of
oilfield tubing that came apart 250 feet downhole. This tubing separation caused the release of high pressure natural gas and the resulting gas well explosion and was therefore a key piece of accident evidence. In
other cases, accident related evidence is retained but not protected. In another example, a high pressure fitting involved in an accident was handled by several attorneys and allowed to roll around in the
attorney's desk drawer before experts could examine the object and take photographs. As a result, the fittings position and condition of the metal fracture were inadvertently but completely altered.
GO TEAM
The goal of (FRAI)
Fast Response Accident
Investigation is to get at least one team of KNOWLEDGEABLE experts onto the accident scene as quickly as possible. This plan requires having a procedure in place that allows legal counsel and the
company's insurer to establish or authorize action by
the "Go Team". The "Go Team" consists of competent, professional accident investigators and can be dispatched to the scene immediately after an accident
has occurred. The "Go Team" is often dispatched under the authority of local or regional counsel.
The National Transportation Safety Board (NTSB) provides a good example of how a "Go Team" operates as part of fast response
accident investigation. The NTSB Go Team, which responds to aircraft accidents and other transportation related catastrophes, consists of trained, experienced and professional accident investigators who are ready
at a moment's notice to respond to an aircraft accident or any other major accident.
The "Go Team" approach works very well for the NTSB because the Federal Aviation Administration (FAA), which monitors airborne
aircraft, knows almost immediately when an aircraft accident occurs. The NTSB then can,
almost immediately, dispatch a "Go Team" team appropriate to the aircraft's type and size to the
accident scene. The mission of the
"Go Team" is to secure the
accident site; photograph and document whatever
accident evidence and/or accident debris may be important; gather, preserve and analyze the evidence and debris; and prepare a factual report
concerning the accident.
The dispatch process for the "Go Team" has to be well planned, with specific procedures in place. First and foremost,
most companies will not have an organization such as the FAA to provide immediate notification whenever an accident occurs. From the company perspective, the risk manager and/or corporate counsel has to ensure
that the company has a procedure in place for alerting and dispatching the "Go Team". For example, at one major oil field service company, all field supervisors, who are present with work
crews at each well site, are under explicit instruction to call the company attorney whenever an accident occurs that results in bodily injury or property damage. The attorney, who is authorized and has the
ability to contact each member of the "Go Team" at a moment's notice, determines the seriousness of the accident and, subsequently the necessary level of response. From plaintiff's counsel
view, the process is identical, get competent "Go Team" members to the accident scene as soon as possible.
Depending on the severity of the accident, the attorney decides if one, two or all three "Go Team" members are to be
dispatched. In the case of a particular oil field service company, its "Go Team" has substantial credentials: Two members hold doctorates in engineering and each have over 30 years of accident
investigation and expert witness/litigation experience. The third member has a bachelor's degree in petroleum engineering and 40 years
of experience.
A big advantage to using a "Go Team"
is that it ensures that trained experts, who may eventually serve as testifying expert witnesses, are involved in the initial accident investigation. Although in many cases safety officers, investigators, insurance
adjusters, risk managers, and various members of the company's management team may be present during the on-site investigation, the "Go Team" members are probably the only ones present who have the experience and
training to analyze the situation and the credentials necessary to allow them to testify as expert witnesses.
However, as our society has become more litigious, additional interested parties and/or their representatives often want to, and have a right to
become involved in the investigation. As a result, if there are others present who wish to get involved, the "Go Team" members can be authorized to obtain written agreements concerning the
alteration and or preservation of any physical evidence. To ensure the integrity of the evidence, the "Go Team" should photograph and remove or secure all critical evidence. It is vital
that evidence be stored and evaluated under controlled laboratory conditions.
To get the best results from a fast response accident investigation, risk managers should ensure that "accident" operational
procedures are designed to immediately notify and dispatch the "Go Team". Any delay could result in lost or altered accident evidence. In light of this fact, the fast response plan will
work somewhat less effectively if the procedure is initiated after some time delay. If the insurer is responsible for sending out the "Go Team", the risk manager and/or corporate counsel
should make sure that the team is quickly dispatched to the scene by notifying the insurer immediately after an accident has taken place.
Some companies will be able to respond to an accident more quickly than others. For example, most companies that sell a service have a
person on-site, and can thus respond immediately in the event of an accident. In addition, some manufacturers have a close relationship with their customers, thus placing them in a position to know about
an accident shortly after it occurs. However, other firms, particularly large manufacturers such as automotive companies, have little knowledge or control as to how their product is being used. In some cases,
these companies will have to wait until after litigation is initiated before they can conduct an investigation as to how and why the accident occurred.
Analyzing the Evidence
The job of sifting through and examining accident evidence
is tedious and painstaking. In most cases, when the expert receives the accident evidence
from someone else who recovered it at the accident
scene, it will be in the form of various bits and pieces of
accident debris.
The accident evidence will usually not be backed up by any type of site
distribution map or evidence location photographs taken before the debris was moved off-site. However, the investigation can be facilitated through the microscopic analysis of evidence that can reveal
"witness marks," showing that a fragment made contact with another object, a burn pattern, or some other form of
physical "fingerprint".
At the end of the investigation, many pieces of the puzzle may still be missing, but in most cases the engineering expert will be able to
assemble the pieces that are available into a meaningful whole. The goal of the accident causation or root cause analysis is to discover how and why the accident occurred. Only after the accident root cause
has been ascertained can the issues of liability and exposure be ascertained
by the legal process. As has been demonstrated, employing the fast response accident investigation concept immediately, is the surest way to secure the
accident site,
preserve important accident evidence and ensure that the accident investigators have the best opportunity to conduct a thorough analysis
of accident evidence and debris..
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Dr.
R. Craig Jerner, Ph.D., PE specializes in accident
investigation and metallurgical failure analysis,
with over 30 years experience as a metallurgical
consultant and accident investigator. He has
testified as a metallurgical expert in over 250
depositions and more than 70 court appearances. If you or someone you know should need the services of Dr. Jerner and J.E.I. Metallurgical, please visit our web site at the buttons below, or e-mail Dr. Jerner --- 