The intent with incident investigations is to find out what happened in the aftermath of an incident or an accident. Normally the intent is to go beyond finding causes in the sharp end of the organisations in order to trying to identify systemic factors that contributed to the incident to happen.
In the sharp end of an organisations, people work directly against the hazardous process where errors risks having direct severe consequences. However, instead of looking at who made the error we look into the organisations, towards the blunt end of the organisations. In the blunt end we find regulators, authorities, decision-makers etc., that all contribute to shape the working environment for the people in the sharp end. In many incident investigations this is the blind spot.
We have used the methodology from Kelvin TOPSET as foundation for the incident investigation as this is the preferred method by this operator. This method is based on root cause analysis and uses the building of a logic tree to unveil the actions leading up to the incident/accident. This method can be used to all types of incidents, from pure technical failures to organisationsal failures. However, we supplemented the root cause analysis with a separate analysis of Human and Organisationsal Factors as a separate services when completing this type of investigations. Consequently, and opposite of finding and categorizing people’s shortcomings, we identified and presented systemic factors leading up to the incident. This has enabled the organisations to more profoundly identify risks associated with safety-critical tasks and consequently created a safer system to work in for the people, the environment and for company reputation. The Human and Organisationsal incident investigation approach can be used regardless of incident investigation method used.
For this global operator we have acted as expert advisors for a number of process safety incidents.
Improvements on organisational learning and enabling progress on safety and productivity.