Week 4 Seminar

1. Week 4 Seminar Investigating Significant Injuries and Lessons Learned

2. Objectives • The objective of the investigation of a significant injury • Components of an investigation team and their duties • The investigation process for a significant injury or death • The lessons learned from massive scale incidents • The role of incident management and the parallel between fatality incidents.

3. Investigating Significant injuries • Investigation of an injury or a LODD is one of the most important activities we must conduct • Extremely stressful circumstances • Pressure for rapid release of information • Investigations are critical to improving safety of members of the organization • Identify deficiencies and make corrective recommendations

4. Objectives of the Investigation • Determine the direct and indirect factors • Satisfy requirements of Public Safety Officer Benefits (PSOB) including: • Identify inadequacies • Situations of unacceptable risk • Indentify actions to be taken • Provide FACTUAL information • Ensure full documentation • Ensure lessons learned are communicated to prevent future occurrences

5. The Investigation Team • At least 5 individuals and should be reassigned from regular duties to focus efforts towards investigation • Team leader • Investigation coordinator • Safety specialist • Team members • Technical specialists • Professional standards officer

6. The Investigation Process • Requires both time and effort • Should focus on factual information • Present the facts of what happened • Identify the factors • Recommend appropriate corrective actions • Investigation team is placed in a difficult situation • cooperation

7. Conducting the Investigation • Authority having jurisdiction • Police homicide section • Line of duty death investigation • Arson investigation • Criminal acts

8. Securing the Scene • Scene of the incident should be guarded and secured • Police assistance • Log maintained of all personnel entering and exiting the secured area • The scene is maintained until approved by the investigation team • Documented, photographed, measured

9. Seizing Evidence • All items that could have bearing should be impounded and protected until turned over to investigation team • Physical evidence • Investigators responsibility of physical evidence • Locating • Collecting • Identifying • Storing • Examining • Arranging for testing

10. Documenting Physical Evidence • Physical evidence documentation checklist • Goal of describing the incident is to record position of people, tools, apparatus and elements of physical environment • Scene documentation should be treated as crime scenes • Diagrams • Photographs • videotaped

11. Additional Investigation steps • Examining physical evidence • Identifying witnesses • Conducting interviews • Developing a time line • Obtaining records of the incident • Researching documents • Using outside assistance • Legal advice • Written report

12. Lessons Learned from Investigating Incidents • In reviewing case histories and investigation materials, departments are able to extract lessons learned. • Whether a large scale event or small incident, there is information that can be used to keep firefighters safe. • The key to examining any case or investigation is to educate responders so that a repeat tragedy does not occur

13. Massive Scale Incident Lessons • RAND/NIOSH report Protecting Emergency Responders: Lessons Learned From Terrorist Attacks • WTC 2001 vs. OKC Bombing 1995 • Problems include chemical, biological, environmental, physical problems encountered by responders • Personal Protection Equipment limitations • Respiratory and vision protection limitations

14. Incident Management • IMS applies to all incidents • Personal Accountability • Keokuk, Iowa • Marks, Mississippi • Worcester, Massachusetts • Size up and risk management • Resource management

15. Summary • Investigation of a LODD or injury is critical to improving safety of members • Direct vs. indirect factors • The steps in the investigation process should be followed at a minimum and may be expanded to gather all of the necessary facts surrounding the incident • Lessons learned from any tragedy to prevent repeat incidents • “those who cannot remember the past are condemned to repeat it”