Serious accidents and incidents happen routinely, and it is crucial for companies to respond effectively, with an in-depth investigation that enables understanding and learning. Each incident should be considered as a learning opportunity to discover the true underlying causes of the adverse event to learn from them, rather than attribute blame.
It is particularly distressing when an injury happens more than once at the same organisation, indicating that lessons are not being learnt. Responding to accidents and incidents is at the heart of preventing them from repeating, so it is crucial to identify what went wrong and take reformative steps. This is the core principle of an incident investigation.
What is an Incident Investigation?
Incident investigation is a process for reporting, tracking and implementing change in response to workplace accidents.
An effective investigation requires a methodical, structured approach that begins with information gathering on equipment, procedures and the event in question. Input is expected from a number of stakeholders, not only the ones present when the incident occurred. Once there is sufficient information, analysis of the failings that led to the incident can take place. The findings will form the basis of an action plan to prevent the accident from happening again and for improving your overall management of risk.
Which Events Should Be Investigated?
Not all incidents merit a full incident investigation, the decision is partly down to the judgement of health and safety management. Weight should be given to the consequences — or potential consequences — of the incident and the likelihood of it happening again.
Who Should Carry Out the Investigation?
For an investigation to be worthwhile, it is essential that the management and the workforce are fully involved. Depending on the level of the investigation (and the size of the business), supervisors, line managers, health and safety professionals, union safety representatives, employee representatives and senior management such as directors may all be involved. As well as being a legal duty, it has been found that where there is full cooperation and consultation with union representatives and employees, the number of accidents is half that of workplaces where there is no such employee involvement.
How Most Companies Do It in Practice?
When investigating an incident, organisations often use a pen and paper during data collection to make note of all relevant details, this information is then typically analysed using sticky notes in an office to drill down to the root cause of an incident. The “5 Whys” method will often be used with a heavy focus on the materials and process side of things. Unfortunately, in these cases there is often only a nod towards the human factors causal factors, that means key factors that lead to the incident may be missed, not addressed and lead to a recurrence of the incident.
Frequently, those conducting the analysis of the incident are not fully acquainted with the full range of human factors elements that may have contributed to the incident, and in some cases are not from the organisation itself but from external organisations sometimes based a distance away from the site where the incident occurred.
The problem with these approaches is that aspects of the incident may be missed in the sticky notes investigation, and these notes will require electronic capture once the investigation has been complete. This adds to the workload of those carrying out the investigation and increases the possibility of information being lost due to misplaced sticky notes. Although steps may be taken to ensure a systematic analysis of the different aspects of the incident, parts of the process may be missed or not analysed as deeply as they could be as there is a reliance on memory of what should be reviewed when it comes to assessing the contributing human factors elements. Where external individuals have been brought in to conduct the investigation and analysis, they may lack the local knowledge and insight required to fully understand what went wrong.
SUPPA™ (Scan – Understand – Predict – Plan – Act) Investigative Model
All human performance and interactions with systems come down to our human biology and so, every human failure traces back to the cognitive origins including mental processes of perception, memory, judgment and reasoning. To understand human behaviour, Integrated Human Factors (IHF) analyse these cognitive origins by using the SUPPA™ (Scan – Understand – Predict – Plan – Act) investigative model that is based on situation awareness research to facilitate the integration of human factors into incident investigation. Situational awareness describes a dynamic process where an individual takes in information from the outside world (Scan), makes sense of it (Understand) and then uses this information — in combination with their own knowledge — to Predict and Plan for what will happen next (Act). The process is dynamic as the individual’s awareness and knowledge of the situation and environment — their “mental model” — is being continually updated.
The Benefits of Implementing Incident Investigation Software
IHF SaaS HF-AIR™ is a comprehensive and focused incident investigation software designed using best practices from human factors experts with integrated analysis tools that enables organisations to investigate technical failures and human errors in a centralised digital solution.
IHF SaaS HF-AIR can enable enterprise-wide visibility of the full accident and investigation process using visualisation tools such as dashboards. These can be organised by human factors topic and a timeline featuring behavioural and non-behavioural causes such as machinery, methods, materials, mother nature and measurement causes with recommendations that can be specifically tailored to your organisation. These analysis tools allow you to focus on each critical step of the incident, drill down to the contributing factors (including those associated with the individual and the organisation) and develop a clear understanding of why the incident occurred. This makes it easier to identify recommendations for improvement to ensure that the incident — or one like it — does not occur again.
Once the analysis has been completed and recommendations have been identified, this information can be easily downloaded within the format of a branded report that captures all of the information provided in a well laid out, easy to read word format. This structure can be tailored to your organisation to ensure that it fits your reporting structure and styling. Furthermore, the intention with this software is to train your employees to use it, providing them with ownership and a developed understanding of what leads to and may cause an incident.
IHF SaaS HF-AIR also provides you with the ability to conduct a top-level analysis of all of the investigations conducted within your company. For example, the opportunity to identify across the different incident types what proportion of critical moment types have occurred, and the type of cognitive and 5M causes have been more likely to occur. Furthermore, IHF SaaS HF-AIR provides a central space for all documents including incident records and interview notes. This enables easy access of information for reference and auditing purposes at a later date and helps to ensure that no information is lost with staff changes.
If you are interested in a demonstration of IHF SaaS HF-AIR then please get in touch.
