Six steps for successful incident investigation - Risktec

STEP 1 – IMMEDIATE ACTION · STEP 2 – PLAN THE INVESTIGATION · STEP 3 – DATA COLLECTION · STEP 4 – DATA ANALYSIS · STEP 5 – CORRECTIVE ACTIONS · STEP 6 – REPORTING. Sixstepsforsuccessfulincidentinvestigation Sixstepsforsuccessfulincidentinvestigation   Organisationsinvestigatebusinessupsetsbecausetheyarerequiredtobylawortheirowncompanystandards,orthepublicorshareholdersexpectit.But,whateverthemotivation,thegoalistoidentifywhytheincidenthappenedandtotakeactiontoreducetheriskoffutureincidents. Investigationsoftenfindthatsimilarscenarioshaveoccurredpreviouslybut,foravarietyofreasons,didnotresultinseriousconsequences.Thisisincreasinglyrecognisedinhigh-riskindustrieswhere“nearmisses”arealsoinvestigatedaswellasincidentswhichactuallyresultedinloss. Asix-step,structuredapproachtoincidentinvestigation(Fig1)helpstoensurethatallthecausesareuncoveredandaddressedbyappropriateactions.   Figure1–Sixstepsofincidentinvestigation     STEP1–IMMEDIATEACTION Intheeventofanincident,immediateactiontobetakenmayincludemakingtheareasafe,preservingthesceneandnotifyingrelevantparties.Theinvestigationbeginsevenatthisearlystage,bycollectingperishableevidence,e.g.CCTVtapes,samples.   STEP2–PLANTHEINVESTIGATION Planningensuresthattheinvestigationissystematicandcomplete.Whatresourceswillberequired?Whowillbeinvolved?Howlongwilltheinvestigationtake?Forsevereorcomplexincidents,aninvestigationteamwillbemoreeffectivethanasingleinvestigator.   STEP3–DATACOLLECTION Informationabouttheincidentisavailablefromnumeroussources,notonlypeopleinvolvedorwitnessestotheevent,butalsofromequipment,documentsandthesceneoftheincident.   STEP4–DATAANALYSIS Typically,anincidentisnotjustasingleevent,butachainofevents.Thesequenceofeventsneedstobeunderstoodbeforeidentifyingwhytheincidenthappened. Whenaskingwhy,weneedtoidentifytherootandunderlyingcauses,aswellasthedirectcauses.Failuresandmistakesdon’tjusthappenbythemselves;organisationsallowerror-enforcingenvironmentsthatencouragedirectcausestodevelopandpersist.Suchenvironments,andthebasicmanagementfailingsbehindthem,aretherootcauses–theultimatesourceoftheincident. Whilehumanerrorplaysapartinthemajorityofincidents,peoplearenotgenerallystupid,lazy,forgetfulorwilfullynegligent.Humanerrorsoccurbecauseofinfluencingfactorsassociatedwiththework,theenvironment,anindividual’smentalorphysicalabilities,theorganisationanditsmanagementsystems.Anyinvestigationwhichsetsouttofindsomeonetoblameismisguided.   STEP5–CORRECTIVEACTIONS Manyinvestigationsmakethemistakeofraisingactionswhichdealonlywiththedirectcauses–aquickfix,puttinglast-lines-of-defencebackinplace.Byignoringtherootandunderlyingcauses,notonlydotheymissanopportunitytoreducetheriskofrecurrenceoftheincident,buttheyalsoleaveopenthepossibilitythatother,dissimilarincidentsmayalsooccur,arisingfromthesame,commonrootcause(Fig2).     Figure2–Thepotentialforasinglerootcausetoresultindifferenttypesofbusinessupset   STEP6–REPORTING Theinvestigationisconcludedwhenalloutstandingissueshavebeenclosedoutandthefindingshavebeencommunicatedsothatlessonscanbeshared.Communicationmechanismsincludeformalincidentinvestigationreports,alerts,presentationsandmeetingtopics.   TOOLSTOHELP Checklists,proformasandposterscanbeusefulwhensettingtermsofreference,collectingandstructuringinformation,analysingcauses,etc.Therearealsosoftwaretoolsavailabletohelpwiththeentireincidentinvestigationandanalysisprocess,forexampleTOP-SETGovernors’Investigator3(seeBox1),andalsoforrecordingandtrackingincidentstatistics,theircausesandtheactionsarisingfromtheinvestigation.   Box1 –Investigator3   ThisarticlefirstappearedinRISKworldIssue14. 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