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Have we overly complicated incident investigation to the point that it’s nearly impossible for organizations to keep up with them effectively? Are incident investigations done to “please” the software? Would the time spent on incident investigations be better spent on prevention?
The answer to all three questions is yes. Investigations can be simplified, and organizations are better off spending time monitoring and responding to weaknesses in their risk management system.
We’re not suggesting that organizations abandon investigations. Instead, we’re challenging the paradigm that treats every incident as though it’s unique.
Identifying incidents with serious injury and fatality potential is a positive and important shift for the safety field. It allows organizations to drive investigation activities based on an incident’s potential. This approach works well for any incident, whether it involves process safety or personal safety.
However, if the existing investigations system is substandard and getting to the root causes is a challenge, the additional investment in investigative resources only results in more confusion about causation and ineffective corrective actions.
We also see many organizations stuck in a paradigm of looking at incidents individually without learning from previous, similar incidents. Although longitudinal analysis of incident data is helpful, it doesn’t typically identify fundamental deficiencies in exposure control management systems.
We have to ask ourselves: If we have three “fall from height” events, does it make sense to do three time-consuming root cause investigations? It’s doubtful the three incidents were independent.
Starting at the beginning
The purpose of an incident investigation is to understand two things:
- Which factors existed that influenced people to make decisions contrary to controlling the exposure?
- Which elements of the risk management process failed, leading to an exposure that remained unidentified and/or uncontrolled?
This means putting the exposure into context. An uncontrolled SIF exposure results from a breakdown in the risk management process. If the SIF exposure was scheduled (a planned working from height, etc.), then a failure to control the exposure is without a doubt a breakdown in management system controls – if they even exist. If the SIF exposure was unscheduled (a machine suddenly jams and a quick decision is made), understanding the context of decision-making is important. For example, decision-influencing factors such as urgency pressure, safety climate and fatigue can be greater in unscheduled exposures.
In the personal safety space, the exposures that create SIF potential are limited – usually fewer than 10. At the operational unit level, the list is often even smaller. Therefore, it’s feasible to have a targeted SIF prevention program for each SIF exposure.
In process safety, the number of exposures that can cause SIF incidents is larger but still manageable. The key is to prioritize the list and work from highest frequency of occurrence to lowest frequency of occurrence.
A preventive approach
The following elements need consideration in each targeted SIF:
- What is the governance structure for the program?
- Which metrics will be tracked to access the health of the SIF potential risk management plan?
- How will SIF exposures be initially and systematically identified?
- What approach will be adopted to eliminate the SIF exposure?
- When a SIF exposure can’t be eliminated, what management controls will be put in place to ensure it remains controlled?
- How will the plan address unscheduled SIF exposures?
If we work upfront to build out a risk management plan targeted at SIF exposures, incident investigations become much less daunting. Simply pull up the risk management plan and start asking targeted questions about the effectiveness of the plan.
In process safety, organizations likewise need to move away from viewing investigations as singular activities and instead take advantage of living documents such as well-designed risk registers and hazard and operability studies. These documents typically have a detailed analysis of exposures and controls. They can serve as the foundation for conducting incident investigations, as they provide a valuable resource to help identify whether the exposure was overlooked or if the controls didn’t function as anticipated – and, if not, allow the investigation to focus on why not.
This will be an easy leap for companies moving to this new paradigm because they have detailed and targeted risk management plans for their SIF exposures. For others, it’ll be a big undertaking. These companies either lack a risk management plan or have a gap in knowledge about risk management.
Final thoughts
We aren’t convinced anyone really likes doing incident investigations. It’s more rewarding to work on the preventive side, addressing system flaws before someone suffers.
Although no organization can completely step away from the incident investigation process, refocusing the approach allows more time to improve the deficiencies found within a management system and, ultimately, safety performance.
This article represents the views of the authors and should not be construed as a National Safety Council endorsement.
Don Groover is the general manager of DEKRA North America (dekra.us). He works with senior executives and leadership teams throughout the world to help them develop an understanding of the current state of exposure control and to develop strategic safety-driven culture change.
Mike Snyder is the managing director for DEKRA North America’s process safety practice. He is an occupational and process safety leader with extensive chemical and municipal risk management sector experience, who guides organizations in pragmatic and cost-effective risk management decision-making.
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