Conducting effective event investigations underpins a performing Error Management System
Reducing risk and protecting people from harm: event investigations are an integral part of an organisation’s Safety Management System. Developing the skills to conduct event investigations effectively and creating a culture that encourages open reporting are areas where we have significant expertise and experience.
There are hazards in all workplaces and risk control measures are needed to reduce the risks to an acceptable level in order to prevent incidents and events. The occurrence of an adverse event suggests that the existing risk control measures were inadequate and learning lessons from near misses can prevent costly accidents in the future.
An investigation is not an end in itself, but the first step in preventing future adverse events. A good investigation will enable you to learn valuable lessons which can be applied across your organisation. The investigation should identify why the existing risk control measures failed and what improvements or additional measures are needed.
Investing in effective investigations offers many benefits
- The prevention of further similar adverse events
- The prevention of business losses due to disruption, lost orders and costs
- An improvement in employee morale and attitude towards safety
- Employees will be more cooperative in implementing new safety precautions if they were involved in the decision and they can see that problems are dealt with
- Investigating accidents and incidents develops managerial skills which can be readily applied to other areas of the organisation
Challenges you might be facing
As an investigator, you try to be objective and trust in your organisation’s open culture and ‘no blame’ philosophy to ensure errors are properly reported and investigated. Yet the same mistakes keep happening…
- You need to know what to do about recurrent errors and find out why they are happening
- You need a fresh perspective on investigation techniques and tools
- You need help establishing a more effective Event Review Group
- Interventions in your organisation are often erratic and inconsistent, and variable in terms of effectiveness; you need help creating more effective processes and procedures.
- You need help implementing and promoting an open, reporting culture
- You want to know more about Just Culture and what benefits it can bring to your organisation
- You need some help embedding Just Culture principles into your Human Factors training programme
How we can help
All our services are designed to facilitate permanent improvements and leave a legacy of improved competence and organisational performance. Through our hands-on investigation scenarios delivered in our training courses and consulting programmes we can help you to:
- Analyse results/evidence and risk assess your findings more effectively
- Improve your error and pro-active reporting rates
- Improve your investigator skills and interview techniques
- Handle difficult situations more effectively
- Understand how to use industry investigation tools effectively – such as the Baines Simmons FAiR® System and MEDA
- Reduce your organisation’s exposure to risk
- Improve the performance of your Just Culture policy
- Perform your role more successfully and increase your contribution to your organisation’s management of safety
How our FAiR® System can help you
Our FAiR® (Flowchart Analysis of Investigation Results) System is an innovative management tool for determining the nature of errors. It enables management to understand the causes behind an event and ensure appropriate remedial actions are taken. Simple to use, the tool requires minimal training and can be used by non Human Factors specialists.
Effective investigations give you the ‘why’ – what happens next is the role of the Event Review Group. Does your Event Review Group have the necessary skills and competence to effectively discharge their duties?
- A vital component of an effective investigation system is the Event Review Group. Simply identifying and reporting events and occurences is not enough. How reports are investigated is where you can truly reap the benefits from your error management system, switching it from a functional to a performing management system that supports your business fully.
- Our highly experienced trained investigators can help you know how to assure the root cause and contributing factors have been established so that you can determine effective interventions that will ultimately lead to a range of improved safety benefits including improved availability, greater reliability and reduced costs of rework.