Immediately After an Accident

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To Preserve Evidence for an Accident Investigation

1. Document position of Valves at, and upstream of, accident scene before they're moved and/or before people forget where they were positioned prior to securing the Accident Scene. (Investigators, both amateur and professional, will want to move valve handles to find out if they're full closed or full open. Once they're moved, that information may be gone forever). Don't forget to document positions of the smaller valves like those isolating the traps. These are critical. A dab of white-out in the north position of the valve handle or a photo of the stem position may do the trick.

2. Get written statements right away from each operator and witness in their own hand writing of their description of what happened including conditions prior to the Accident , if they have knowledge of them. They should list their name and job title, what time they came to work, and start out with where they were and at what time they heard/saw/were told what happened. They might sketch a diagram or floor plan if that helps their explanation.

The statements do not need to be elaborate or typed. Later on, the witnesses can be interviewed to flesh out their statements but you want to get the details down before they are mis-remembered (which, trust me, they will be). Ask them to turn in the statements the next day. (I recommend you explain that these statements are voluntary and solely for the purpose of figuring out what went wrong, not about casting blame, and that you follow this policy. The path to minimizing investigation and correction costs at this point is to encourage everyone to be truthful and recognize those who are truthful for the courage that can take.

3. Photograph site in detail before changing or moving anything. It helps to include a person or a hand in the photograph pointing to whatever is the focus of the photo. It gives scale and orientation. Turn the date and time function feature of your camera on to include these in each photo. Label the photos identifying the primary focus of the Picture. Later photos, after changes are made, must be distinguishable from after-accident photos.

4. Record the amount of condensate drained. If valves are opened, determine if there's condensate to be drained. If more than a quart or so, catch and measure it. It's important to know where lots of condensate built up and if it's hot.

5. Develop Time Line of Events culminating in the Accident. Try to nail the exact time of the Accident and what events preceded it.

6. Collect steam pressure and flow charts or recordings from the Boiler Plant and any metering that may show steam conditions leading up to the event.

7. Find "elevation" drawings showing the slope of piping to and away from the Accident site. These drawings should always be in the Engineering Drawing Set or Contractor Shop Drawings from which the site was built. If it's a water hammer accident, I'll need to find out where the condensate collected.

This list is not supposed to replace those measures an attorney might recommend, such as isolating the Accident Scene to preserve evidence. These suggestions are based on my experience investigating steam accidents and the pain of reading depositions taken well after the accident to decipher what happened.

W. Kirsner, 26 June 2009

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