Is the quality of your incident investigations poor? Do you fail to learn valuable lessons from investigations? Do you regularly see “operator take more care” as the root cause of your investigation (a common result in ICAM)?
THE GOOD NEWS IS THAT YOU ARE NOT ALONE.
Poor incident investigation is probably the most common fault across businesses today. Due to a lack of understanding of why we investigate, leaders will commonly push investigations to be completed ASAP. Instead of learning valuable information, we slip into ‘blame mode’ and tell our workers to ‘take more care in future’, ‘We need to re-train you’.
Poor investigations, generate less than useful outcomes and we do not get to the causes of the incident and the corrective actions RARELY FIX THE PROBLEM.
THERE IS A BETTER WAY.
There is a simple process that will take your leaders ‘from zeros to heroes’ when it comes to investigating incidents. It will also help them demonstrate genuine care and leadership in their sphere of influence.
HERE IS A RECIPE TO GET YOU STARTED – AFTER THE INCIDENT, HERE IS WHAT YOU MUST DO:
- Respond and Notify (this is the law)
- Make sure;
- The injured person is looked after
- Any “second victims” are looked after
- Any damage is isolated and repaired
- Assemble a Post-Event Learning Team
- Determine contributing factors (there will be many)
- Look much deeper than “operator error”
- Document the findings and communicate the report
- Recommend corrective actions
- Management review and implement the findings
- Use Normal Work Learning Teams – find the problems before an incident
Most businesses need help to get started
We have developed short, practical training courses that will help your staff to understand the learning process. Beyond the training, we regularly provide coaching in learning teams as a stand-alone process or part of a larger organisational culture process.
Learning teams can help, with the aim of creating and enabling effective safety systems that will allow humans to fail safely (meaning, without resulting in unacceptable consequences). Build better more effective workplaces, do not try and build a better or perfect human.
Good quality learning allows your organization to build on events and adapt. It is one of the key drivers for improving organizational culture. Also, have a look at Safety Differently