Quality studies, incident investigation

In three exercises, I collected a total of 905 incident investigation reports completed by supervisors for an analysis of the quality of incident investigation. With emphasis, I state that the study I made would not meet the modeling and methods requirements of scientific inquiry. Nevertheless, some interesting observations were made. 

Causal factor determination varied greatly as to quality In some of companies, it is poorly done. How poorly It was necessaiy to report to some of the safety directors who provided investigation forms that on a scale of 10, their incident investigation systems scored a 2. (See Chapter 11, Incident Investigation Studies of Quality.)... 

Why a study of the quality of incident investigation There are three major elements in practice of safety preoperational (in the design process) in the operation mode (integrated within a process of continuous improvement) and post-incident (after a hazards-related incident has occurred). 

At the locations where the quality of investigations was good, it was determined that safety professionals had made much of the subject in their giving counsel, and management insisted on the job being well done. Also, as was found in previous studies, incident investigations conducted by teams produced exemplary reviews of causal data, in depth. 

For how many hazards-related incidents has the work situation set a trap for injured workers In Chapter 11, Incident Investigation Studies of Quality, I wrote that in a substantial number of the investigation reports collected as a part of a study project, entries suggested that further... 

However, the record is clear—incident investigations can be done effectively. In some companies, incident investigation is done well because the safety culture will not tolerate anything other than superior performance. In the studies I made of the quality of investigations, some companies scored an 8 out of a possible 10. (More than one safety director has accused me of being a hard marker.)... 

Incident Investigation Studies of Quality Hazard analysis is the most important safety process. If that process fails, all other processes are likely to be ineffective. Incident investigation serves as one, vital basis for hazard analysis. Several studies of the quality of incident investigations were made by this author to provide an information base for consideration by those who undertake to improve investigation systems. Unfortunately, this author has concluded from the studies made that this vital element in operational risk management is very often done poorly. 

Why make studies of the quality of incident investigations There are four major elements in operational risk management ... 

It is a fundamental—if hazard identification and analysis do not relate to actual causal factors, the resulting corrective actions will be misdirected and ineffective. Safety professionals could profitably consider the results of the four studies made by this author of the quality of incident investigations and select from the observations made the findings that could be applicable as a base for improvement in the organization s to which they give counsel. 

To study the quality of incident investigation as actually performed, a collection was made of 537 reports completed by supervisors and investigation teams from 37 locations of 11 organizations. 

For how many incidents have the decisions affecting the sociotechni-cal workplace and work methods resulted in situations that are conducive to operator errors In Chapter 14, Incident Investigation Studies of Quality, it was said that in a substantial number of the investigation reports collected by this author, entries suggested that further inquiry should have been made into the design of the workplace or work methods. In many cases, the investigation reports pertained to incidents that occurred in error-provocative situations. Yet, often in those instances, only unsafe acts of employees would be recorded as the incident causal factors. 

A large number of studies were undertaken to allow optimization of the number, length and location of VRS installed in the roadside and the central reserve of roads fall in the first category. Most of these studies have utilized collated incident data, although the number, quality and relevance of the incidents investigated should be understood, in all cases. The results of these studies will be reported in the next sectiom... 

---