avoiding incident investigation pitfalls pursue the right trail presented by: wally cook p. eng....
TRANSCRIPT
Avoiding Incident Investigation Pitfalls
Pursue the Right Trail
Presented by:Wally Cook P. Eng. CRSP CHSMSA President – Kestrel Resources Ltd.
What Frustrates you About Incident Investigations?
Repeat incidents? Poor analysis? Lack of commitment to action? Fear of reprisal? Apathy?
Do Investigations Make You Feel……?
Let’s Look at Incident Investigation …….
Process
Pitfalls
Pointers
The Investigative Process
Reporting Data gathering
AnalysisRecommendations
Corrective actionsFollow-up
Reporting
Gaps Lack of reporting Late reporting Incomplete information
Possible Causes Didn’t know I needed to report Didn’t seem important Too busy to complete
information - production pressure
Pushback – retribution, job security
Afraid of medical treatment “Red tape” involved with forms
– too complicated
Solutions to Reporting Gaps
Explain the “what and why” to all personnel Orientations Feedback on actual reports
Streamline reporting Give timely feedback on actual reports Push back on the push back mechanisms
Data Gathering
Gaps Information inaccessible
Site already cleaned up
Witness went home to Newfoundland
Witnesses hesitant to provide information
No interviews, using witness statements only
Hearsay vs. facts
Possible Causes Inadequate site securement Misunderstanding of data
required Improper scene management Witness perceptions - blame
agenda Easier to review statements
than speak to witnesses Time requirement
Comfort with conducting an interview
Poor interview technique
Solutions to Data Gathering Gaps
Clear incident response roles and responsibilities – line vs. “safety guy” Assign scene commander/lead investigator
Identify data sources early – scene, witnesses and relevant documents
Formal training - incident data preservation, interviewing etc.
Clearly communicate purpose of investigation to interviewees
Always seek witness interviews in addition to written statements
Separate fact from opinion
Analysis
Gap Corporate policy – We only do
immediate cause analysis on low risk events
95% of incidents rated low risk Mars vs. Venus risk perception Focus on human (victim)
behavior Can’t find a cause in the pull
down menus Lack of detail – cause type vs.
actual cause
Possible Causes Corporate commitment Rating based on actual loss
not loss potential Task familiarity - perception
that risk is lower than actual Single individual defines risk
of event Easier to focus on injured
rather than system issues Model limitations or
restrictions
Solutions to Analysis Gaps
Develop investigator skills Critical thinking Interviewing Writing
Tune investigation model Don’t be a slave to the model
Risk rate based on loss potential Use an investigation team
Recommendations
Gap Corporate culture
They’ll never buy that!
Saying that would be career limiting
Difficulty speaking truth to power
Suggesting what is easy to fix Favorite recommendation(s) Recommendations don’t relate
to identified causes Need to get an answer to
company or client ASAP
Possible Causes Corporation has no interest in
learning or improvement Investigators afraid or unable
to speak to management Interest in closing out a file
promptly Poor use of process – training,
attention to detail etc. Unrealistic expectations –
corporate or client contract documents
Solutions to Recommendation Gaps
Confirm corporate culture Line management needs to own the process Willingness to learn from mistakes Commitment to continuous improvement
Learn to speak to management Engage management on the investigative team Align recommendations to causes “Acid test” recommendations Manage final reporting expectations
Corrective Actions
Gap Actions do not actually
address the causes Corrective actions
vague
Possible Causes Easier to “do something”
than address the issue Filling out a CAR keeps the
corporation happy Inadequate oversight of
suggested corrective actions
Easy to sign-off on a non-specific action
Solutions to Corrective Action Gaps
Quality Assurance Design and use an effective review process Seek specific details in CARs Discuss improvements
Follow-up
Gap Actions not completed Action completed,
problem still remains
Possible Causes Undefined progress and
completion times Actions not assigned to
specific individuals Cause analysis
inadequate
Solutions to Follow-up Gaps
Set corrective action completion targets Ask
Are corrective actions completed? AND Did actions resolve the issue? AND What “baggage” is attached to the action?
Re-analyze if action did not solve problem Address the “baggage”
What are the Root Factors Behind These Pitfalls and Traps?
Key Target Areas – Effective Investigations
Enhance corporate culture Tune investigation tools
Realign software packages
Invest in skills for investigators Engage management Quality-check investigation results Follow-up
Did we do what we said we’d do? Did it resolve the problem? What “baggage” comes with the action?
Wally Cook P. Eng. CRSP CHSMSA President – Kestrel Resources [email protected]