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Page Title: Determining the Sequence of Events
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Table  4-1.—Witness  Information  Chart Sometimes   developing   a   chart   of   your   witness and your “best guess.” Some  investigators  write  the information (table 4-1) is helpful. Determining the Sequence of Events Now   that   you   have   your   sketches,   evidence, photographs, video tapes, and witness statements, you can determine your sequence of events. That is the most difficult part of investigating a mishap, especially a complex  mishap.  You  must  take  all  the  events surrounding  the  mishap  and  put  the  jigsaw  puzzle together. In some mishaps you have logs and records that aid you in pinning down times and people. Start with the times you do have; then fill in the blanks with testimony sequence of events on small pieces of paper and arrange them into different sequences until a possible chain of events appears. Your chain of events can start days or weeks before the mishap even occurred. Look as far back as needed to  find  a  cause  that  could  prevent  recurrence. Maintenance done on an aircraft 6 weeks ago could be a contributing cause to an aircraft crash. Disconnecting a backup warning bell on a forklift last year may have contributed to a worker’s being run over last week. All of these may be part of your sequence of events. Your sequence of events may also be extremely short.  A  welding  spark  touching  off  a  pyrotechnic device  that  detonates  other  ammunition  that  blows  out 4-14

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