Historically incident investigations have been seen as reactive in nature. We failed to prevent an adverse outcome and so we investigate to try to understand where things went wrong, what happened and more importantly why it happened so that we can try to prevent it from happening again.
It is a reactive process that if conducted effectively should result in proactive improvements in an organisation’s incident prevention measures. Incident investigation should be seen as risk management in reverse - the investigation enables us to recognise where the organisation initially failed to identify and manage the risks and now has an opportunity to implement effective controls to manage the risks to prevent future similar occurrences.
More recently there has been discussion in industry about completing investigations before having an incident, commonly referred to as ‘pre-incident’ investigation and I am often asked how this is achieved, especially with respect to the Incident Cause Analysis Method (ICAM). Pre-incident investigations (proactive use of incident investigation models) give organisations an opportunity to identify what they are doing right and where things could go wrong as opposed to focusing on where things did go wrong.
It’s an opportunity to review the adequacy of current controls, to discuss where the potential for unwanted events exists, to identify what is required for continued safety success and to apply this to other areas of business. If an organisation takes the time to identify activities, processes and projects where they have had no major incidents reported and they use the ICAM principles to identify areas where things could go wrong then they start to become more resistant to incidents, after all “complacency should not be allowed to develop as a result of long periods without an accident or serious incident. An organization with a good safety record is not necessarily a safe organization” – Flight Safety Digest. By taking this approach we shift the organisations focus to preventative safety, as opposed to being reactive and focusing on investigation findings.
During the incident investigation we work through the ICAM model from right to left, as seen in the image below. We start at the event and reverse engineer the incident by focusing on:
Identifying the Absent/ Failed Defences: these are the control measures which did not prevent the incident or limit the harm from it. We identify not only the defences that were present that failed, but those defences that were absent (a reasonable expectation of what should be in place). Examples include interlocks, isolations, guards, barriers, JSA, SOPs, Awareness, Supervision, Emergency Response and PPE.
The Individual/ Team Actions: these are the errors or violations that led directly to the incident and are usually committed by the frontline operators and maintenance personnel.
The Task/ Environmental Conditions: these are the conditions that existed immediately prior to or at the time of the incident which directly influence the way humans and equipment perform in the workplace. These are the circumstances under which the errors and violations took place, such as poor resourcing and tool availability, fitness for work, lack of knowledge, change of routine etc.
Organisational Factors: lastly we look back to the decisions made in the past by designers, engineers, managers etc. that seemed to be a good idea at the time but did not necessarily understand the ramifications of those decisions further down the line. These are the underlying organisational factors that produce the conditions that affect performance in the workplace.
When using ICAM proactively at the start of an operation we work in the opposite direction, from left to right.
We use the Risk Management model to identify the management controls required to reduce risk, such as formal risk assessments, design reviews, training requirement assessments and procedural/ policy standard requirements (the Organisational Factors within the ICAM model for error prevention).
We then identify the conditions that influence individual and equipment performance and what’s required in order to maintain a safe workplace (the Task/ Environmental Conditions within the ICAM model).
On a daily basis our operators do a lot of risk-based decision-making using informal JSA tools such as Take 2, Take 5 and 5 Point Safety Cards to try to identify errors before they result in adverse outcomes (the Individual/ Team Actions in the ICAM model).
Lastly we focus on the controls that are, or should be, in place to trap and/ or mitigate errors (the Absent and Failed Defences within the ICAM model).
Once we have identified those potential issues within the system we then develop and implement controls to ensure we close the gaps to prevent any adverse outcome. If we are successful we achieve the desired outcome of safe and efficient task completion. We are looking at a closed loop system: when things go wrong we use the ICAM model to get it right we use the Risk Management model (see figure below).
Using ICAM as a proactive tool further provides an opportunity to understand how we are achieving good safety performance. Any time we can proactively identify our strengths and weaknesses and use this information to work towards achieving Zero Harm, we are adding significant value in the organisation. In theory then, the value of pre-incident investigations should be clear: we gain valuable safety learnings without the cost of injuries (and often unfortunately death), equipment damage, production loss, environmental impact etc. But we also need to be realistic. How many of us are able to spend valuable time assessing what we are already apparently doing right when there is so much else that requires our attention?
Ask yourself the following questions:
Do you know where your next incident lies?
Do you really have a clear understanding of your risks?
Are you being effective at managing risks or is it luck that got you to this point?
Is it just a matter of time before you have a catastrophic event?
We don’t know what we don’t know, so if we don’t take the time to assess and understand how we are achieving these results then how confident are we that we are actually getting it right? It is impossible to demonstrate that we have been proactive and prevented something from occurring because it never happened and thus we can never be 100% confident in our ability to prevent an incident unless the hazard or risk has been completely eliminated, and this is often only at a prohibitive cost.
The same principles are applied to corrective actions regardless of whether completing a pre-incident or post-incident investigation. Using the hierarchy of controls and ensuring our corrective and preventative actions are as high up on that hierarchy as reasonably practicable gives confidence in our ability to prevent an incident or, at a minimum, reduce the risk around the activity.
Ideally, organisations should be focused on continuous improvement and thus should be doing both proactive and reactive investigations. Regardless of the method that is followed the quality of these investigations is largely dependent on the investigator’s skills and the level of organisational support. The organisation must consider who is selected to be part of that investigation team bearing in mind that their investigation skills, their knowledge of the activities that were taking place at the time, any potential biases, and relationships with those involved in the events may influence the direction and potentially the outcomes of that investigation.
Interested in Knowing More?
Further information on Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Mary-Jane Vince (Investigator/Trainer)
Mary-Jane has 12 years’ experience in the mining industry in Africa, North and South America developing best practice EHS management systems built across entire life of mine processes, from exploration, permitting, greenfield/brownfield construction, start up and commissioning, operations and closure.
The combination of technical skills and knowledge supported by practical industry experience with people of different cultural backgrounds has given Mary-Jane a high level of communication, understanding and adaptability to provide effective health and safety advisory and training services.
Her work has brought her into many unique and sensitive operating environments and as a result she is comfortable in multi-cultural stakeholder engagement, working with organisations, local communities and government to find mutually beneficial solutions to challenges in mine operations, expansion, rehabilitation and closure.
Mary-Jane joined the Safety Wise team in 2012 working in North America and Botswana, before recently relocating to Canada providing ICAM training, investigation and consulting services for clients in multiple industries.