Team-based incident investigation

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. 

The incident investigation management system may include a description of how a team is organized and how it functions. The team organization, composition, and functions must be structured to provide flexibility based on the particular incident and the management system should emphasize that fact. The system may describe an investigation team s basic objectives... 

The team leader s responsibilities need to be explicit. Normally a team leader chosen for more serious or more complex incident investigations will be independent from the operation or facility where the incident occurred. Actual team composition may vary significantly based on the nature of the process and the degree of technical sophistication. This flexibility of team composition is an important feature of a well-designed incident investigation management system. 

An incident has just been reported. How is a team activated The team activation segment of a company s incident investigation management system should guide the user to assemble a team based upon the following two areas of concern ... 

The fact/hypothesis matrix is another valuable tool available to the incident investigation team. This tool is used to compare the known facts against the various hypothetical scenarios. The matrix can help clarify thinking. It makes it easier to determine the most likely scenario and to refute other proposed scenarios based on the available facts. Using a matrix can help the team avoid jumping to conclusions and selecting a... 

Based on their incident evaluation, management will put together the formal incident investigation team (which will usually have a similar composition to that of the Go Team) as illustrated in Figure 11.3. 

This author has examined more than 1700 incident investigation reports completed by supervisors and investigation teams, mostly for incidents that occurred in larger companies and that resulted in serious injury or fatality. In approximately 80 percent of those reports, causal factor information was inadequate. These reports are not a sound base from which to analyze and conclude with respect to the reality of causal factors. 

A well-conducted incident investigation has content-based validity. However, it is difficult to assess the other two types of validity. For criterion-based validity, we are not aware of what might be used as a criterion. We might look at the correlation between system causes of quality problems, as discovered by process-improvement teams, and the system causes of incidents. We would expect to find considerable overlap. If we failed to find this overlap, we might question the validity of either or both classes of investigations. 

At the base of the why tree where fundamental management systems are implicated, the process ceases. The investigation team should then focus its efforts on the rigor and quality of the management systems that could have prevented the incident. Recommendations are developed to address system deficiencies and these are tested against the why tree. An example is included on the accompanying CD ROM. 

The composition and mandate of a team will vary depending on the specific incident. Within a large organization or a company with several very different processes, it may not be practical or desirable to preselect one team to investigate all incidents. Personnel should be selected to participate in investigations based on tbeir specific skills, experience, availability, and tbe team roles tbat need to be filled for a particular investigation. Over time, tbis approach will produce a pool of trained and experienced employees familiar with the investigation process. 

An investigation team leader is generally selected based on three factors related to the incident ... 

While the use of predefined trees does not directly challenge the investigation team to think laterally of other possible causes, many predefined trees present a wide range of causal factors, some of which the team may not have otherwise considered. It is therefore possible, but unlikely, that the incident could involve a novel root cause that was not previously experienced by those who developed the predefined tree. The addition of a final test based on another tool, such as brainstorming, can overcome this apparent weakness. 

The role of the team leader is to establish the analysis team, obtain consensus on the objective, and build trust and consistency in the analysis process. All type of fault finding must be eUminated and no fingers must be pointed. Copies of the standard operating procedures should be read before a team member investigating an incident. All results and recommendations must be based on facts, not opinions. 

Step 3 Identify one key systemic factor that was instrumental in causing the accident/incident. This step is concerned with identifying one key systemic factor that played an instrumental role in causing the accident/incident. It is to be noted that this factor must be based on all team members consensus and serves as a starting point for further investigation. 

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