Incident Investigation by TheSafetyMaster

TheSafetyMaster™ conducts accident investigation or incident investigation for their clients and provides training and consultancy services in this field

Let’s overview steps of accident investigation

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           Identify the incident

The first step in conducting a successful incident investigation is to recognize when an incident has occurred so that it can be investigated appropriately.

The heart of the issue is that members of an operating investigation team all share a common language that supports their investigation objectives efficiently and accurately.

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     Investigation Team

The second step in conducting a thorough investigation is to assemble a qualified team to determine and analyze the facts of the incident. This team’s charter, using appropriate investigative techniques and methodologies, is to reveal the true underlying root causes.

·      

      Investigative Techniques

Fault Tree - Fault Tree Analysis (FTA) provides a structured method for determining the causes of an incident. The fault tree itself is a graphic model that displays the various combinations of equipment failures and human errors that can result in an incident.

Fishbone Diagram - The fishbone diagram is a simple tool that allows quick and effective root causes to be understood, in the pursuit of corrective actions. In a fishbone diagram, the various causes are grouped into categories and the causes cascade from the main categories, flowing towards the effect, forming what resembles a fishbone appearance.

·        

     Report Generation

The third step in incident investigation is to generate a report detailing facts, findings & recommendations. Typically, recommendations are written to reduce risk by:

• Improving the process technology

• Upgrading the operating or maintenance procedures or practices and upgrading the management systems.

After the investigation is completed and the findings and recommendations are issued in the report, a system must be in place to implement those recommendations.

·       Hazard Evaluation

     Basic fundamentals for near miss reporting, incident, emergency, crisis, hazard identification, Risk Evaluation by What if checklist, Bowtie, FMEA shall be covered.

·       Incident Investigation

     Any safety management system requires a clear governance and management organization without which system can’t be effective. In this session how to form a risk-based governance structure for II shall be covered with RACI of each member shall be explained for II Subcommittee

·        Investigation procedure

     Steps how investigations and root cause analysis (RCA) are performed. It explains the importance of near miss and incident reporting and investigation as a proactive tool to control risk before losses/harm occur. This will also develop understanding of investigations, including reporting & how to interview

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      Root Cause analysis

      Analyzing data for all human physical or system factors. Determining ALL root causes of each factor. Identifying root causes using the Root Cause “Fishbone Diagram” & “Fault Tree Analysis” techniques.

·         

      Report & Communication

      Report preparation through a case exercise shall be covered with a focus on employer information, incident details, description, root cause analysis, sequence of events, team structure, factors, nature of injury and many more points. All formats shall be shared. Further how-to communication and take action on preventive and corrective actions

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     Case Studies

Each topic shall be covered with lots of case studies, group exercises, interaction and experience sharing.

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