Checklists investigation tools

Checklist analysis tools can be a user-friendly means to assist investigation teams as they conduct root cause analysis.h) Each causal factor is reviewed against the checklist to determine why that factor existed at the time of the incident. The Systematic Cause Analysis Technique (SCAT)(9> is an example of a proprietary checklist tool. 

The checklist has been used as a design tool as well as an accident-investigation tool in cases where human errors have played a central role. It draws attention away from blaming the person that made the error. Instead, it focuses on the identification of dysfunctions in the design of the man-machine system from an ergonomics point of view. The intention is to identify accident-prone workplaces rather than accident-prone persons. 

This chapter addresses methods and tools used successfully to identify multiple root causes. Process safety incidents are usually the result of more than one root cause. This chapter provides a structured approach for determining root causes. It details some powerful, widely used tools and techniques available to incident investigation teams including timelines, logic trees, predefined trees, checklists, and fact/hypothesis. Examples are included to demonstrate how they apply to the types of incidents readers are likely to encounter. 

If the deductive process has stalled and no further progress seems possible or likely, then the iterative loop calls for application of inductive investigation methods such as a checklist or HAZOP. The inductive methods may also benefit from use of the fact/hypothesis matrix tool described in this chapter. 

Checklists of varying content and detail are used in incident investigation methodologies as a user-friendly tool to assist root cause analysis. Sometimes a comprehensive checklist may be used as the primary root cause analysis tool, or alternatively a checklist may be simply used to supplement another primary tool. 

These checklists are useful tools that prompt the reader systematically to pose simple questions which aid in the critical assessment of the study. The first question prompts the reader to consider the overall validity of the research question. Did the investigators explain the problem... 

These checklists are useful tools that prompt the reader systematically to pose simple questions which aid in the critical assessment of the study. The first question prompts the reader to consider the overall validity of the research question. Did the investigators explain the problem and why it has not been adequately addressed Are both the costs and the consequences of the drug under investigation included Is the analysis incremental Is the viewpoint (or perspective) of the analysis stated, and is it valid A research question is well defined if it states the perspective and alternatives and makes it clear that both costs and consequences were to be compared. 

The checklists on deviations and causal factors in Tables 6.8 and 6.11 have been designed according to the first principle. Different studies show that the use of tools designed according to this principle improve the reliability and coverage of data collection in accident and near-accident investigations (Kjellen, 1983). 

SMORT is also suitable for use as a tool in the planning and execution of SHE audits. The steps of a SMORT investigation, as described in Section 13.6, follow the basic procedure of an audit. The SMORT checklists and questionnaire give support in the development of detailed lists of questions for the audit. 

Efforts should be made to simplify the form for the registration of accidents and near accidents as far as possible. It is an important principle that the design of the form shall not create a barrier towards the reporting and investigation of accidents and near accidents. Some of the data are fed directly into the computer and need not show up on the form for the supervisor s first report. No specific form is needed for the in-depth investigations. Checklists should be developed to support the investigations. There are also other tools to be considered such as checklists and record sheets for use in workplace inspections, risk analyses and SHE audits. 

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