The Best Incident Investigation Performance Indicator
If an incident investigation and the corrective actions are effective, it will prevent, or significantly reduce the likelihood or consequences of, a repeat incident.
If we want to monitor the effectiveness of our incident investigation, root cause analysis, and corrective action processes, probably the best performance indicator is monitoring the rate of repeat incidents.
If an incident (or even a Causal Factor) is a repeat, it indicates that there was a problem with the previous investigation. For example:
- Was the root cause analysis inadequate?
- Were the corrective actions ineffective?
- Why didn’t management or peer review catch the problem with the previous investigation?
Of course, the question that is tough to answer is … What is a repeat incident (or Causal Factor).
Judging repeat incidents takes some soul searching. The real question is, should have the previous incident investigation prevented the current incident.
Here are two examples:
- Should the investigation and corrective actions for the Challenger Space Shuttle accident have prevented the Columbia Space Shuttle accident?
- Should the BP Texas City fire and explosion accident investigation have prevented the BP Deepwater Horizon accident?
You be the judge.
What is the rate for your facility? Do you have 80% repeats? 10%? 0.1%?
Each repeat incident provides a learning opportunity to improve your incident investigation, root cause analysis, corrective action, and incident review processes. Are you using these opportunities to improve your system?