Accident Investigation Protocol - getting the Events to Learn from

The accident / incident investigation protocol describes the process to learn form from unwanted events such as accidents, incidents, complaints, etcetera.

The main items that should be part of an accident investigation protocol are given below:

Purpose

The importance of learning from unwanted events should be made clear. This can be done in various ways: written communication, training, toolbox meetings etc.

The main reason for learning from unwanted events is to eliminate and reduce undesired or unwanted events and their consequences such as:

• human suffering
• material damage
• liability claims
• product losses
• company image damage
• loss of clients

with the aim to:

• maintain good stakeholder relations
• control production cost
• optimize continued profitability

What? Whom? When? How?

It is important to define what unwanted events should be reported, investigated and analyzed, by whom, when and how and how remedial actions shall be managed to completion. The broader the definition of "unwanted event" is, the more opportunities there are to improve the efforts to eliminate and/or reduce human suffering and unnecessary cost of production.

Cause - Consequence model

It is important to accept a model that relates the unwanted event and its outcome to the management system. That way a manageable system can be set up and communicated in which all levels in the organization will be able to play their roles. The "domino model" provided via this website is generally accepted and can be easily applied to various areas of business management: safety, quality, cost control etcetera.

Classification of Risk

For involvement and attention of higher management levels in the investigation, analysis, development and follow-up of remedial actions, it is important not only to look at the actual results of an event but - even more so - to establish what the results could be if circumstances would have been slightly different. A small fire noticed during the initial phases could be extinguished easily but when unobserved, it could grow to a catastrophe taking many lives and causing unprecedented damage.

Determining the potential risk is the objective of risk classification. The outcome of the risk classification process helps to determine:

• which levels of management should be involved
• which method should be used fro investigation and cause analysis
• whether a team approach should be used to contribute to investigation and analysis; possibly including (external) expertise
• the management level of the team chairperson
• selecting remedial actions and deciding budget provisions

Cause Analysis

The protocol shall determine when a "root" cause analysis shall be carried out, depending on the level of risk classification.

Such root cause analysis is best carried out through a team approach. Preferably these analyses should be done under the guidance of a "facilitator" with sufficient knowledge and expertise with the analysis system being used. The role of this person is of particular importance if the analysis data will be put in a data base for future use and retrieval of information.

Systems used for cause analyses may include: SCAT (Systematic Cause Analysis Technique), MORT (Management Oversight and Risk Tree); Causal tree ("Arbre des Causes") and others. A good investigation report form may also be of help when supported by a good protocol. 

Responsibilities

Clear responsibilities should be established for:

• reporting of accidents / incidents defined in the protocol
• investigation of these accidents / incidents to collect facts
• cause analysis to uncover the causes that have led to the accident/incident
• development and follow-up of remedial actions

Responsibilities should preferably be put in writing and communicated to the persons concerned.

Training, Instruction, Communication

People with important roles in the "Learning From Accidents" process should know what is expected from them and how they should carry out their roles in the process.

These roles are to include all important steps as indicated under "Responsibilities" above.

Conveying the message could range from instructions to operational personnel during toolbox- or safety meetings to more extensive (external) training of facilitators in acquiring the techniques to be used in carrying out the investigation and the cause analysis.

Investigation Team

An investigation team should be used as determined by the level of the risk classification or otherwise.

The team can also be used to convey the importance of learning from accidents to all people on the investigation team. Of particular importance to also include operational personnel as it will convey to them the importance of reporting accidents / incidents. At the same time higher management levels should be included whenever possible to demonstrate their management commitment and support through taking remedial actions to eliminate or prevent similar events in the future.

The investigation team approach is "top down - bottom up" in practice.