Near Misses are great opportunities

One of the interesting discoveries I’ve made after years of investigating incidents is identifying things that were wrong, but not a factor in causation; although they could cause a different problem in the future.

This is because, using the scientific method, several potential scenarios that could lead to the event are identified and then tested against the evidence to either prove, or disprove them. This well-established methodology helps, among other things, to reduce possible biases and ensure that less obvious scenarios are included in the study.

An effective incident investigation requires a team-based approach involving multiple disciplines from Engineering, Operations, Management, Supervision, Maintenance and possibly some subject matter experts. Crucially, operators and technicians must be a key part of the team to make the study effective. There should be a facilitator who may, or may not be, part of the site operations team.

Sounding a bit like the make-up of a HAZOP team?  Absolutely!  But this time we have a team that is not just theorising on what might go wrong, but have a real event to tackle. I’m not knocking HAZOPs here, that are probably the most essential tool in the box; rather highlighting the value of getting such a team together and find out what actually happened and why.

The benefits of an effective incident investigation study not only include identifying the root causes, that are typically associated with management systems and associated practices and procedures, but also:

-          Identifying and testing safety barriers and associated weaknesses

-          Identifying other problems that could lead to a different incident in the future

-          Imparting knowledge and learning to the team of people involved in the investigation

-          Encouraging a questioning approach to problem solving

-          Develop a reporting culture (reporting near-misses is good!)

-          Sharing skills and experience of the team

-          Demonstrating that the site management takes such events seriously, thereby helping to build the safety culture of the site

-          Doing something different from the day-to-day activities – and it is often much more interesting.

I was lucky enough to be part of the team that developed the latest CCPS book on incident investigation, summarised in the paper: https://www.icheme.org/media/19410/hazards-29-paper-30.pdf.

So why not start doing more investigations when you had a near miss or things just aren’t working so well?  These are great opportunities to get a team together and focus on operational and safety improvements that could prevent a bigger incident from happening next time.  If you need some help please don’t hesitate to get in touch.

rog@rogerstokesrisksolutions.com