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.
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.