#Incident investigation
Comprehensive incident management and accident investigation at industrial enterprises. Moving from mere blame-seeking to deep root-cause analysis (5W principle) and building a proactive culture. Transforming routines for 'Target Zero'.
Direct Line with HSE Leaders: Alexander Pivikov
A comprehensive approach to transforming corporate safety culture by engaging top management in regular audits (gemba), digitizing key HSE processes (audits, investigations, electronic permits-to-work), and replacing fines with positive motivation tools and pass blocking. Allocating specialized departments for safety culture development separates compliance tasks from cultural initiatives.
Safety Cycle: A Cumulative Tool for Achieving "Target Zero"
The "Safety Cycle" tool is a visual clock-face board for regular spaced repetition of information about past incidents and top risks of a unit. Every week, the focus shifts to a new incident, which is addressed through informing, monitoring corrective actions, and visual reconstruction (shock content), while the management of the tool is transferred to line managers.
"Learning from Mistakes" or How to Conduct a High-Quality Incident Investigation
Implementation of the A3 incident investigation methodology to shift from blame-seeking to systemic root cause analysis. The practice includes a step-by-step fact-gathering algorithm, application of analysis tools (timeline, cause tree, Ishikawa diagram, barrier diagram), and evaluation of corrective actions using an effectiveness-cost matrix.
Integrating Contractors into the Client's Digital Solutions
Integrating contractors into the client's unified digital environment using a large industrial complex as an example. Implementation of electronic permits-to-work, automation of audits, and incident investigations involving contractors.
Aspects of National Context in Nuclear Safety Culture
An analysis of the impact of deep-seated national traits on safety culture in the nuclear industry, based on studies in Japan and India. It explores the adaptation of safety management tools considering traits like fear of failure, diligence, and the tendency to remain silent about problems.
Fire, Water, and Brass Pipes of Safety Culture
Implementation of an open incident and error reporting system, abandoning punitive measures. The practice includes shaping desired behavior, motivating by management's personal example, creating accessible communication channels (e.g., QR codes), and high-quality incident investigation to find root causes.
HSE Strategy and Production Strategy: Points of Intersection
Integrating HSE strategy into production processes by including safety metrics in managing directors' KPIs, applying incident investigation methodology to analyze equipment downtime, and implementing the right to stop unsafe work. The practice also includes scaling safety standards to contractors by integrating them into the corporate risk management system.
Off-the-Job Injuries: In the Employer's Spotlight
The article is devoted to the experience of an enterprise in recording and analyzing off-the-job injuries as an important source of information on the effectiveness of the occupational health and safety system. The author describes the creation of an automated data collection system based on electronic sick leave certificates, carrying out preventive measures, and implementing KPIs for managers. The practical benefit of the approach lies in reducing staff interest in concealing work-related inju...
SPAS Card: Saving Lives and Preventing Violations
The article discusses the Emergency Situation Prevention System (SPAS) at the company "ASIA DRILLING", designed for the timely detection of minor violations and the prevention of workplace incidents. With the help of SPAS cards, employees can record hazardous actions, demand a work stoppage if necessary, and thereby protect the health of colleagues and the safety of equipment. The material describes the procedure to follow when a risk is detected, as well as an employee incentive system for cont...
Incident Investigation: Tools and Methods
The article is dedicated to tools and methods that help systematize the incident investigation process and identify their true and systemic causes. The material describes the sequential application of the 5W&1H, 4M analysis, and "5 Whys" methods for problem formulation and detailed analysis of event factors. Using these approaches allows evaluating the situation from all sides and systematically conducting an incident investigation.
Incident Investigation in Industrial Safety
Despite the development of a proactive approach and the concept of "zero harm", occupational accidents continue to occur, creating serious risks for both employers and employees. The article addresses the need to move from formal incident investigation and assigning blame to identifying their systemic causes. This approach helps to effectively eliminate occupational safety risks, prevent the recurrence of incidents, and minimize their consequences.
Incident Investigation: How to Stop Making the Same Mistakes?
The article reveals a practical approach to internal incident investigation at an enterprise, helping to turn abnormal situations into a source for improving the safety system. The author explains how to create an atmosphere of openness without fear of punishment, properly collect facts using the L.O.R.D. system, and effectively conduct witness interviews. The described algorithm for using analysis tools and an automated system helps identify systemic causes of incidents and develop effective co...