Incident Investigation
The Opportunity
Our client experienced several repeat process, containment and personal safety incidents. Investigations of the incidents identified:
- Quality of investigations was deemed as poor
- 50% of investigations were carried out by untrained people
- Failure to identify the root cause contributed to recurrence.
- 70% of incidents without consequence were thought to be misclassified.
- Self-verification of investigations identified that human factors analysis has rarely been applied in investigation.
- Confusion internally on when & how to apply Health, Safety & Environment (HSE) & Repair & Maintenance (R&M) 5-why methodologies.
Approach Taken
To address this a team, consisting of HSE, Operations, R&M were brought together to undertake a Value Stream Mapping session. Over 157 issues were raised these issues were then addressed in a Kaizen event. During the event the team:
Streamlined: Self verification protocol defined; simplified 5-why report template; review of Circumstances form replaced with simple after action review.
Standardised: refreshed understanding of classification options in a safety management system; unsafe condition/act vs incident without consequence; changed leadership behaviours for when to investigate; Human Factors trained investigators; 5-why competency framework.
Sustain: established KPIs to track/review all improvement areas
Benefits Realised
The team created a “fit for purpose” investigation process with clarity on which methodology should be used when.
Clarity on classification of incidents & finding real root cause resulted in a reduction of “incidents without consequence” unsafe classed as a near miss from 80% to 32%. This correct classification returned 1281 hours back to HSE Team.
100% of investigations now carried out by fully trained investigators, up from 20%, this included Human Factors training.
Move from KPI Management driven interventions to improved mindset and trust.