Accident investigation incident analysis approach

Each accident/incident should be methodically analyzed using an accident investigation/root cause analysis approach. Because many root cause analysis methods exist, it will be the investigator s responsibility to select the appropriate analysis approach (e.g., barrier analysis). Use of proper accident/incident investigation methods and tracking will lead to intervention, which will successfully prevent further occurrence of these occupational accidents and incidents. 

Truly, to learn more about how to prevent injuries from an analysis of an incident, we need to approach the task with a different mindset. It is not "accident investigation"— it is "incident analysis." This simple substitution of words can have great impact. We can get more employee participation in the process and reap more benefits. I suggest the following shifts in perspective and approach toward the evaluation of a near hit or injury. 

Two articles by investigative reporters at the Wall Street Journal (WSJ) indicate the potential value of a more thorough approach to comparative analysis of performance indicators. The first, published shortly after the Macondo accident, found that for each 100 million hours worked offshore during the years between 2004 and 2009, U.S. operations incurred 4.84 worker fatalities, more than 4 times the European rate of 1.07 fatalities, and experienced 5 major losses of well control in 2007-2008, whereas 5 other major countries (Norway, United Kingdom, Australia, Canada, and the Netherlands), with about half as much drilling activities, reported no such incidents. ... 

Other accident analysis and investigation approaches that make explicit reference to supervision as a potential causal factor include AcciMaps (Svedung and Rasmussen, 2002), which diagrams company management and technical, operational, and management failure levels, and the Incident Cause Analysis Method (ICAM) (BHP Billiton, 2001), which addresses inadequate supervision and poor supervisor or worker ratio error modes. 

This paper indicates that the use of taxonomies from a bi-dimensional approach such as CREAM to classify data is a potential solution to produce meaningful information from three different types of source using the same framework (i) historical data, as demonstrated in this research, plus (ii) incident investigations and (ii) prospective analysis, as in the original application of CREAM HRA. The common framework to conduct human reliability predictions as well as retrospective analysis of events during Human Reliability Analysis in a specific facility or industry is perfectly able to interface with the proposed classification scheme for past accidents, considering that they basically share the same taxonomy. 

---