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Toolbox Tips #1 (Part 8a) - The Concepts of Incident Causation

Kevin Stretton - Monday, March 14, 2016

Summary of Part 7

 

In Part 7 we came to understand not only how human and social factors can influence our perceptions of incident causality we also determined that incident investigations can be a valuable tool for concentrating efforts on the continual improvement of management systems. 

 

Objectives of Part 8:

 

By combining an engineering & social approach, understand & apply the basic concepts of causality when:-

Designing management & work procedures [Safe / Standard Operating Procedures (SOP’s) or Work Instructions (WI’s)].

•    Completing an incident investigation.

 

So that through continual improvement and time, elimination of hazards & the prevention of error becomes the norm.

 

Part 8a:           Modern or recent incident investigation techniques

 

There are a variety of models available for incident investigation.

    Can you choose the one that is right for you &/or a variety of incident scenarios?

    Is there a ‘one size fits all’ model that can be used for everything like environmental, quality & safety incidents?

 

The answer to both these questions is yes, only if we redirect our thinking to the analysis & continual improvement of management systems because all systems direct & influence the way employees, executives, managers & supervisors operate.

 

This means focusing our techniques on (a) in the timeline and progressively working backwards through time to recall & trace the sequence of events.

 

        

This is the only way we can create a culture that is focused on prevention rather than reaction.

 

Thought about carefully this model can be applied to any incident, not just one involving employee illness or injury.

 

Some examples:

1.    Product or service recall following a customer’s complaint.

2.    A chemical spill that found its way into a natural water system.

3.    A financial error causing incorrect allocation of resources.

4.    A safety device which failed when being used by an employee under standard conditions.

       5.   Protective equipment being used incorrectly by an employee
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