Lecture 11 - Incident Investigation and Analysis

Question 1

What is root cause analysis?

Answer 1

• There are many different methods, tools, processes, and philosophies available for use when performing a root cause analysis
• RCA is a tool for continuous improvement
• Supported by taxonomies (categorisation systems) of various types of root causes
• Trending over time for frequently recurring (combinations of) root causes
• When performed after an incident has occurred, RCA is a reactive method
• When used to audit systems and processes, RCA becomes a pro-active method, enabling the user to forecast the possibility of an incident/undesired event before it occurs

Question 2

What are the steps involved in incident investigation: Step 1 and 2?

Answer 2

1) Immediate incident scene management
- Take any necessary action to prevent further escalation
- Secure the scene so nothing gets changed
- Start collecting information as soon as possible, including photos, video, witness interviews, to protect data from getting lost
- Deal with legal requirements regarding access to the scene and incident notification
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2) Set up investigation team
- Involve various expertises, including subject matter expert, management, investigation expert
- When contractors involved include them in team

Question 3

What are the steps involved in incident investigation: Step 3?

Answer 3

3) Evidence collection
- Photographs
- Videos
- Site sketches
- Measurements – distances, weights, heights, forces
- Samples
- What was the physical environment like at the time of the incident
- Interviews with witnesses and others who may have some insights regarding the occurrence
- Analysis / testing of any failed equipment, parts and materials
- Applicable rules/procedures/standards/manuals/records/log books/communications, e.g.:
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Procedures / Standard Work Procedures (SWPs)
Original Equipment Manufacturer (OEM) manuals
Inspection and maintenance records
Training and assessment records including relevant licences
Pre-task hazard assessments
Recorded radio communications
Written or verbal instructions
Reports of previous incidents, hazard observations and HSE interactions

Question 4

What are the steps involved in incident investigation: Step 4?

Answer 4

4) Analyse Data
- Establish event time sequence / chart
- May identify need for further information collection
- Use suitable incident causation model (see separate lecture on incident causation)
- Identify root causes
- How far back to go to find root causes?
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Do not simply stop at human error
Ask yourself if something is a symptom of an underlying problem
Generally remain within boundaries of the organisation’s control
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- A variety of analysis tools and techniques is available (see separate lecture on tools/techniques)

Question 5

What are the steps involved in incident investigation: Steps 5 - 9?

Answer 5

5) Develop recommendations
6) Record, report & present investigation findings & recommendations
7) Implement actions
8) Review actions
9) Capture & disseminate broader lessons learnt

Question 6

Investigation/analysis success factors
Common investigation/analysis difficulties and how to deal with them
Common investigation/analysis difficulties and how to deal with them

Answer 6

REFER TO SLIDES