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). 

In this third and important element, competent investigation of hazards-related incidents is vital. Effective safety practice requires that actual causal factors—the hazards and events that contributed to the incident process — be identified, evaluated, and eliminated or controlled. 

Thorough incident investigation and follow through with remedial actions support a culture that gives importance to safety. Poorly done incident investigations give employees reasons to doubt management s sincerity with respect to safety. 

HAZARD ANALYSIS IS THE MOST IMPORTANT SAFETY PROCESS 

This statement, with which I emphatically agree and often repeat, comes from MORT Safety Assurance Systems by William G. Johnson. 

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

Postincident— where investigations are made to determine causal factors and develop remedial actions 

Postoperational—when demolition or rebuilding operations take place 

On the Practice of Safety, Fourth Edition. Fred A. Manuele. 

Studies of the quality of incident investigations were made by this author to provide an information base for consideration by safety professionals who undertake to improve investigation systems. Unfortunately, this author has concluded from studies made that this vital element in operations risk management is very often poorly done. 

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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.)... 

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... 

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. 

Mortality data are frequently used in cohort studies as opposed to incidence data because of the relative ease of obtaining information on deaths. In particular, the advent of the National Death Index has made mortality data more readily available. While all states maintain registries of incident cancer cases, many of the registries are relatively new and data quality can vary from state to state. Investigators conducting follow-up studies are required to comply with each state s requirements for use of the data. For cancers such as pancreatic cancer where survival is poor, mortality data is an excellent surrogate for the risk of the disease. For other cancers where the survival is much better, such as testicular cancer, mortality is a poor estimator of incidence. Table 15.5 describes the 5-year survival for several selected cancer sites for the period 1996-2004. As evident from the table, there is a considerable difference in survival rates for cancer of different sites. The 5-year survival rate for pancreatic cancer was only 5.1% compared to a survival rate of 98.9% for prostate cancer (SEER 2008). 

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. 

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. 

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.)... 

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. 

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... 

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