Most of the time, any enterprise operates without emergencies, but when safety barriers fail, we face an incident. Although an incident seems like something purely negative, with the right approach, even such an event can be beneficial.
Investigate, Don't Hide!
We can arm ourselves with the most advanced and trendy incident investigation methodologies and the best, perfectly written standards, but none of this will work properly if incidents are being hidden.
Fear of punishment is a very powerful argument when it comes to hiding an incident. Because of this fear, we lose information about incidents that could help prevent them from recurring. We took the first and most important step toward creating an open and trusting atmosphere in 2022. This is an amnesty based on the results of incident investigations. We do not punish for incidents; we fire for hiding them. I recommend that everyone who wants to implement a modern internal incident investigation procedure start with this very step.
Along with an atmosphere of openness, we worked hard to instill a key idea in the minds of managers: any incident is a way to make our system better. How? By eliminating the causes that led to the incident.
Using our internal business trainers, we conduct training sessions on internal incident investigation.
The Language of Facts
First and foremost, we teach our managers how to respond correctly to an incident — from notifying the dispatcher to preserving the scene in its original state (or using photo/video recording if preservation is impossible). Next, we explain how to collect primary information most effectively and how to separate speculation and emotions from facts. Facts are the foundation of any high-quality investigation. To collect facts, we use the P.E.P.D. system — People, Equipment, Position, Documents. Corresponding checklists were developed for each area. But there is a nuance here. While everything is fairly obvious regarding equipment, position at the scene, and documents, it is quite different with people. Getting facts from an incident participant is a non-trivial task. An incident is always stressful, especially if someone is injured. Stress has a strong impact on a person's ability to react adequately to what is happening. What risks does this pose for us? An incident participant undergoing an improperly organized interview might think they are being blamed and go into a deep defensive reaction, not sharing necessary information or even providing false information. We teach managers proper interviewing techniques — creating a trusting and comfortable atmosphere, empathy, avoiding any attempts to blame or shame the interviewee, explaining the "question funnel" principle (from open to closed questions), and teaching how to separate facts from emotions and speculation.
Revealing the Hidden
After collecting facts about the incident, we use well-known and common investigation tools, not only in safety — the timeline, "5 Whys," and the causal tree. The timeline helps build an accurate chronology of what happened from the facts and then identify the event or condition factors that were critical. The "5 Whys" method and the "Causal Tree" help determine the contributing and systemic causes of the incident.
Once the causes have been established, the final stage begins — the development of corrective actions. When developing them, we adhere to the following rules:
All stages of an incident investigation, from registration to evaluating the effectiveness of the corrective actions taken, are recorded in the automated safety management system (ASMS). Thanks to the use of standardized report forms, unified directories, and classifiers, we receive automatically generated end-to-end statistical and analytical reporting.
Every year, based on incident analysis, we form our plans for the following periods — implementing focused monthly audits, investment programs for equipment modernization, communication programs, and much more, which I will discuss in future articles.