Quality management incident investigation

Effective investigation and analysis of hazards-related incidents is an important element in a quest to achieve superior results in safety. A high quality of incident investigation and analysis not only results in risk reduction, but also serves as a positive reinforcement for the safety policies and practices that management has established. 

Deserves a much higher place within all the elements of a safety management system. Because—The quality of incident investigation emerges as one of the primary markers in evaluating an organization s safety culture. 

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. 

Incident investigation reports may include valuable data on predictive indicators pertaining to serious injury and fatality potential. However, this author has found that the gap between issued procedures on incident investigation and what actually takes place can be huge. Even in the best safety management systems, the quality of incident investigation can be less than adequate. 

It is suggested that internal evaluations be made of the quality of incident investigations to determine what improvements are necessary. Such evaluations often indicate the existence of culture problems demonstrated by the accepted practice for supervisors, management personnel above the supervisor level, and safety professionals to sign-off on shallow investigation reports. 

If this author was involved, his experience would require emphasis on Risk assessments. Prevention through Design, Maintenance, Management of Change, and Improving the quality of incident investigation. 

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

For a major incident investigation using a comprehensive root cause analysis system, teams will be formed to acquire information relevant to determine the structure and analyze the causes in depth. In addition to evaluations of the immediate causes, imderlying causes are likely to be evaluated by investigations in areas such as safety and quality management. Both paper- and computer-based systems will be used to acquire and record information for subsequent detailed analyses. 

Identify the essential features of a management system designed to foster and support high quality incident investigations. 

Most importantly, results of investigations and the actions to be taken concerning causal factors are publicized. Quality of incident reporting and investigation required or tolerated is a principal measure of the accountability system, and of the culture of which the accountability system is a part. It s very difficult to achieve effectiveness in other aspects of hazards management if corrective action is not taken concerning the causal factors for the incidents that do occur. 

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. 

Case 3. A chemical company with 1,200 employees has found numerous ways to include its employees in the site s safety and health program. For example, the Safety and Health Committee, which includes equal labor and management representatives, has responsibility for a variety of activities, such as monthly plant inspections, incident investigations, and examination of any unsafe conditions in the plant. Employees are also involved in process and operations review, safety inspection, and quality teams. Two hourly employees work fulltime at monitoring the safety and health performance of on-site contractors. 

Inspections The quality of inspections made, as reflected by their thoroughness and the actions taken with respect to findings, is another immediate and outward evidence of an organization s safety culture. Hazards and risks may be overlooked when inspections are made because that is what is expected, and actions may not be taken on hazards identified in the inspection process. If that occurs, employees determine precisely that, no matter what management says or writes, management does not intend to have a safe operation. Those unidentified or unattended hazards appear regularly in incident investigation reports. 

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