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Tips to conducting an investigation after an incident

This is an excerpt from Integrated Risk Management for Leisure Services by Robert Kauffman and Merry Moiseichik.


Learn how you can prevent and reduce injury, damage, or loss with
Integrated Risk Management for Leisure Services.

Need for Investigation

This section focuses on the benefits of or the reasons for conducting an investigation after an accident. The reasons for conducting an investigation can vary greatly in terms of purposes and benefits.

Multiple investigations can occur with the same incident. These investigations can overlap each other and conflict with other investigations. For example, in the Dzialo case, Greenfield Community College conducted its own internal study to find out what went wrong in the near drowning of Adam. Then, in an effort to address growing public concern, the college hired Charlie Walbridge to conduct a second study. He was unaware of the internal investigation until after he completed his study. Since Walbridge had conducted an investigation for the college, the assistant attorney general of the Commonwealth of Massachusetts hired this author to review the case materials and to render an opinion on the incident. Because the college was being sued by the Dzialo family, the Commonwealth was also listed as a defendant. Everything other than the college’s study and Walbridge’s study were provided to this author. In addition, the Dzialo family and their plaintiff’s attorney most likely had their own investigation to determine what happened.

In the aftermath of this accident, there were at least four different investigations involving the same incident. Several of the reasons for conducting an investigation are illustrated by the Dzialo case and complement the needs or benefits of conducting an investigation identified by Ferry (1988) below. Walbridge’s study was essentially a duplication of the college’s investigation, as was this author’s investigation of both of their investigations. Although they were essentially duplications, they had very different purposes. The school’s study was motivated toward identifying whether the school needed to make administrative changes to improve their program. Walbridge’s study was motivated by the public for an independent study. This author’s investigation was conducted to independently verify Walbridge’s findings for the Commonwealth.

Adapted from Ferry (1988, p. 4), the following points are often cited as the benefits of completing an investigation. They also help to frame the nature and extent of the investigation, including the selection of the investigator and whether the investigation is conducted internally or externally.

Find out what happened. The primary reason for conducting an investigation is to find out what happened. This is often the simplest and most obvious reason. This was the purpose of Charlie Walbridge’s investigation for Greenfield Community College, and it was the purpose of the Potomac River study.

Prevent future incidents and accidents. This is the logical result of finding out what happened. An investigation can often help prevent future incidents. In the Cody case, the second fatality could have easily been prevented if an investigation had been conducted. By her own admission in her deposition, Janice Cody, owner of Winding River Canoe Rentals, did not conduct any form of investigation or do anything that could have prevented Melanie Carlson’s death one year later. Had she conducted an investigation, she would have noticed that trees in the water were forming strainers and would have identified the danger of Yates Dam at moderately high water.

Improve operations and procedures. Once an organization finds out what happened, the next step is to improve operations and procedures. This is not the same thing as determining negligence, where one seeks to find a breach of standard of care. People often say “I can’t fix that now because that will show we were wrong.” It does not. If an organization is in a lawsuit and it makes changes because of the accident, the court cannot interpret those changes as admitting negligence. The courts want to prevent future accidents. Regardless, an organization may want to work with a lawyer so that the changes do not inadvertently suggest culpability.

Make program decisions. Management can use an investigation to make decisions on current and future programs. If no study is conducted, it can sometimes lead to the wrong decision. For example, an outcome of the Potomac River Study was the implementation of gauges at river put-ins to warn users of potentially hazardous river conditions. Although Winding River Canoe Rentals didn’t make the wrong decision, they didn’t make any decisions or changes that could have increased the safety of their livery. In discussing risk management plans in chapter 8, the Reassessment of Policies and Practices section provides recommendations that could easily have resulted as part the formal recommendations from an investigation.

Help reduce the ripple effect. An investigation allows people to tell the story of what they did. This discussion itself can be therapeutic. In addition, an investigation allows people to voice their concerns and see progress toward solving the problem. (See chapter 13 for a discussion of the ripple effect.)

Help management make risk management decisions. An investigation can often help an organization make risk management decisions or help the industry create risk management standards. For example, the long-term study by Project Adventure of initiative courses resulted in the discontinuation of the electric fence (Collard, 2001; Project Adventure, 1995; Rhonke, 2005). The industrywide study revealed a trend among seemingly unconnected occurrences of people spraining or breaking an ankle on the electric fence initiative. The Potomac River Study can lead to additional investigations on other rivers and lead to management recognizing the importance of moderate flows in river fatalities.

Help protect against litigation. According to Ajango (2005), 20 percent of lawsuits in the health care industry occur because people simply want to find out what happened or what is going on. Conducting an investigation can help protect against litigation because it keeps people informed of what happened and assures them that someone is doing something about the problem. The incident described in figure 12.1 illustrates this point.

Meet insurance requirements. In determining whether to settle or go to court, the insurance company may require an organization to conduct an investigation. Often, an investigation of this nature is involved with litigation.

Satisfy media interest. Depending on the visibility of the incident, an investigative report allows the media to disseminate the correct story. However, the report may prolong the life of the story because it is another topic for the media to report. Walbridge conducted his investigation separately from the internal study that the school had already conducted. He was unaware of the internal investigation when he began his investigation. Walbridge’s study, the results of which were similar to those of the internal investigation, was conducted in response to the college’s attempt to alleviate community and media pressure. His study continued media interest in this highly charged case.


Read more from Integrated Risk Management for Leisure Services by Robert Kauffman and Merry Moiseichik.


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