Advanced Safety Incident Investigation, Analysis Agenda
WEEK 1 – INTRODUCTION TO INCIDENT INVESTIGATION
- Incident investigation and its relationship to WHS management system requirements
- Distinguishing between hazards, near misses, incidents and accidents
- What ‘triggers’ an incident investigation – identifying the level of risk
- Different types of investigation (regulatory, company and legal) and their purpose
- People versus systemic approaches to incident investigation
WEEK 2 – INTRODUCTION TO HUMAN FACTORS AND HUMAN ERROR
- Human factors in context
- A systems model of human factors – the Optimum Human Work Performance Model (OHWP)
- Understanding human error types, causes and consequences
- Organisational error management strategies and the role of error tolerant systems
- Practical error and violation remedy checklist for investigators and auditors
Activity: Identify the error type.
WEEK 3 – A HUMAN FACTORS ANALYSIS METHOD FOR INCIDENT INVESTIGATION
- Critical review of human factors analysis methods
- Errors and error producing conditions
- The role of Critical Control Management (CCM) in identifying prevention and mitigation critical risk controls
- The Loss of Control Analysis (LOCA) model for assessing the efficacy of critical risk controls
- Case Study: Application of LOCA to a significant safety incident
WEEK 4 – INITIAL INCIDENT RESPONSE ACTIONS AND PLANNING FOR THE INVESTIGATION
- Immediate actions
- Securing the site and controlling the hazards
- Notifying relevant authorities and internal managers
- Reporting requirements and WHS legislative obligations
- Completing a notification report – a suggested format
- Incident investigation planning considerations
Activity: Completion of an incident notification report.
WEEK 5 – FINDING FACTS – PART 1
- ‘FOCAR’ (to focus on a problem) – A 5-step approach to incident investigation: Find Facts, Organise Data, Contributing Factors, Agreed Actions & Report
- Step 1: Finding the facts via a structured data collection method
- Asking the right question using the OHWP model checklist
- Case Study: Example data collection process
Activity: Brainstorming data sources using the OHWP checklist.
WEEK 6 – FINDING FACTS PART 2 – WITNESS INTERVIEWING
- A structured approach to witness interviewing
- Progressive interview questioning techniques, probing and behavioural cues
- Dealing with reluctant witnesses
- Documenting the discussion: Example witness interview template
- Example interview
Activity: Interview assessment.
WEEK 7 – ORGANISE DATA VIA A TIMELINE
- Determining the incident and loss of control point
- Identifying post incident events
- Identifying pre-incident events
- Identifying conditions
Activity: Timeline practice.
WEEK 8 – CONTRIBUTING FACTORS
- Identifying Contributing and Non Contributing factors from data collection
- The rule of 3 to determine veracity of evidence – triangulation
- Application of the Loss of Control Analysis (LOCA) model for assessing the efficacy of critical risk controls
Activity: Analysing data and application of LOCA to identify contributing factors.
WEEK 9 – AGREED ACTIONS
- How to develop reasonable agreed actions using the SMARTER principle
- Applying the hierarchy of controls
- Strategies to get your corrective actions accepted
- Developing Key Learnings
Activity: Identifying Agreed Actions and Key Learnings
WEEK 10 – REPORT AND DOCUMENT
- How to develop structured, logical and quality-assured incident investigation reports
- Recommended investigation report structure
- Language and readability
- Example Incident Investigation
- Report templates based on incident severity
Activity: Incident investigation report writing.
WEEK 11 – ACCOUNTABILITY AND CONSEQUENCE MANAGEMENT
- No Blame, Accountability and Fair and Just Culture
- Determining the level of accountability – the notion of intention
Activity: Finalisation and submission of investigation report for assessment.