Incident Investigation is a systematic process to find the root causes of problems and develop effective solutions to improve performance. This article includes:
An incident is:
The worst consequence that
happened in a sequence of events.
The sequence of events describes what happened in a safety, quality, equipment reliability, production, or environmental problem. Thus an incident is the worst safety, quality, equipment reliability, production, or environmental issue in the sequence of events.
It is possible to have multiple incidents in a single chain of events. For example, you could have injuries or fatalities, equipment damage, and an environmental release as part of a sequence of events that includes a chemical plant explosion.
Another type of incident to investigate is a precursor incident. A precursor incident is:
Minor incidents that could have been a major accident
if one or two more Safeguards would have failed.
Precursor incidents may be called close calls or near-misses.
For a more in-depth discussion about precursor incidents, CLICK HERE.
Now that we understand the definition of an incident, we need to find the best way to perform an incident investigation?
The majority of the incidents are low-to-moderate risk incidents, precursor incidents, or close calls (near-misses).
The best way to investigate any incident, even minor incidents that are still worth investigating, is to use a systematic process. That systematic process should avoid common problems (placing blame and cognitive biases) and promote the use of investigation best practices.
Even simple investigations have a minimum set of simple incident investigation best practices to achieve investigation success. What are these best practices? CLICK HERE for an article that explains them.
Is that minimum set of best practices is just too much? Then you have two choices:
What is the difference between a simple investigation of a precursor incident and the investigation of a major accident? That could be the subject of a whole book! But let’s start with the fact that a major accident investigation will be much more complex, will probably have a team performing the investigation, and will have much more management and regulatory interest (and perhaps even a separate regulatory or prosecutorial investigation). Thus a major accident investigation process will have to be more robust to accomplish the goals of the investigation.
Some other difference may include:
An investigator must collect accurate information to perform an incident investigation, find root causes, and develop effective corrective actions. We categorize this evidence as 3 P, and an R. That is:
Here are some tips for collecting better evidence:
For more information on interviewing and evidence collection training, CLICK HERE.
Once you have collected the investigation informant (evidence) and displayed it in a sequence of events, you are ready to find the incident’s Causal Factors, root causes, and Generic Causes. How do you find root causes? See THIS PAGE.
Investigators can fall into traps when developing corrective actions to prevent repeat incidents. What kind of traps? Here are two examples:
What does management need from your report (or presentation) to be able to approve your incident investigation? Here are five critical sections for every incident investigation report:
The best incident investigation performance measure (performance indicator) is your facility’s rate of repeat incidents.
What is a repeat incident? Consider these examples:
Review ten years of your facility’s incident history starting with the oldest incidents. As you progress to newer incidents, do you see repeat incidents, Causal Factors, or root causes?
Generic Causes are, by definition, repetitive. Therefore, every incident with a Generic Cause is probably a repeat incident.
What is the repeat rate for your facility? Do you have 80% repeats? 10%? 0.1%?
We hope that this incident investigation guidance has helped you develop ideas to improve your safety, quality, equipment reliability, operational excellence, and human performance investigations. If you would like our help analyzing and improving your incident investigation program, please contact us by CLICKING HERE or calling 865-539-2139. Or if you want to progress from a reactive based incident investigation program to a proactive performance improvement program using state-of-the-art root cause analysis tools, once again, please contact us.
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