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Ime Alfred  
#1 Posted : 01 September 2012 15:38:05(UTC)
Rank: Forum user
Ime Alfred

What is the best investigation tool/techniques for analyzing the root cause of a near miss?
Bob Shillabeer  
#2 Posted : 01 September 2012 17:07:45(UTC)
Rank: Super forum user
Bob Shillabeer

If you are looking for an off the shelf process I think you will fail to get anything that really works. There are some that look very good but they won't cover all aspects that well. I worked in the rail industry for over 44 years and saw quite a few systems but none that worked fully until about 1990 when the industry introduced a system of formal inquiries carried out by several experts covering operations, civil engineering, signalling, per-way. It was easy to identify the prime causes as these were often clear from the outset for example the Hither Green derailment of the excursion train from Brighton was because the driver and his secondman had been drinking with their mates in Brighton but the root cause was a lack of management supervision to prevent drinking alcohol which led to the introduction of the Drugs and Alcohol policies that now exist. Another serious accident was at Grey Rigg were the points came apart under a West Coast express resulting in the death of one elderly lady the root cause of which was poor maintenance practices by Network Rail employees. These were identified by looking beyond the immediate causes by using people with the respective background knowledge and standing back from the actual incident itself something that differs in many industries and takes some learning. There are training courses available and IOSH held one I attended in 2005 which was quite good and was run by a company called Kinaston Associates Ltd (I don't know if they still provide such training but worth a try) via IOSH.
boblewis  
#3 Posted : 02 September 2012 09:39:36(UTC)
Rank: Super forum user
boblewis

BP produced a very good analytical tool in the nineties but I think with the demise of Sir J Brown it has fallen into disuse.It was part of their No Accident, No Harm to people No damage to the environment system. I have a copy of the flowsheet but it is A1 size and PAPER not electonic. They had a Model Report that led investigators through.

To redo it from the flowsheet is time consuming but could be done via one of my colleagues I will pm you some info.

Bob
Nick Davidson  
#4 Posted : 02 September 2012 12:35:19(UTC)
Rank: New forum user
Nick Davidson

For low potential near misses I find three people and five why's generally works well if you get them to do their own five why's and then discuss.

For Higher potential near misses and actual consequence incidents something like TapRoot or Kelvin TopSet are quite good but require training and some investment to get going. TapRoot is also American biased in terms of language so can be rather verbose.

If money is no object and if you are in a complex industry something like Tripod Beta Lite or full is good but takes a huge amount of effort to set up.

SAP also have a tool in their HSE module, but I have not seen it or know if they still have it. This may be an option to explore if your organisation uses SAP.

Good luck finding one that works for you and your company as Bob says not that easy!
teh_boy  
#5 Posted : 03 September 2012 07:27:47(UTC)
Rank: Super forum user
teh_boy

There is no best tool

but I have used http://www.hse.gov.uk/pubns/priced/hsg245.pdf to get relatively inexperienced managers to investigate root cause.

IOSH managing safely has a good module on this too!
SafetyGirl  
#6 Posted : 03 September 2012 07:42:21(UTC)
Rank: Forum user
SafetyGirl

Ime,

I'm getting the feeling here that these guys are doing all your study for you???

I think Seebee summed it up nicely last week when he said that members don't mind having subjects to debate, but your posts don't actually bring topics up for debate / discussion - you've not even had the decency to re-word your study topic questions.

Perhaps I'm being a Monday morning grump, but go and do some research first, come to the table with something other than spouting the questions verbatim.

iyenoma  
#7 Posted : 04 September 2012 12:43:31(UTC)
Rank: Forum user
iyenoma

Ime Alfred,

PM me or send me a mail on my email contact: iyenomaosazee@yahoo.com

Regards,
Iyenoma.
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