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”