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.


PBI Success Story – Incident Investigation