I investigate using a few methods and RCA to me is too linear a process which is why you get to those end points which are really starting points, great for machine/equipment failure but limiting for operational failures. If you’re getting to these issues you must ask what’s wrong with the training, procedures, risk assessments etc that causes people not to follow them. If the folk are just bad people how did you manage to hire them. I am sure however, there are other reasons, it's probably not those things that are the problem it’s usually how the work is arranged in reality and the variability that doesn’t allow people to follow training, procedures etc.
Human error, training etc should be the starting point. RCA's tend to look at conditions rather than methods, so does 5 why etc. You need to understand how the work is done v's how it was planned (look up Erik Holnagell and safetyII). There you will find the gaps, these are going to be where the workers deviated from the plan but there will be a reason why it made sense for them to make that deviation (this is called local rationality, have a look at Sidney Dekkers Field Guide to Human Error and Todd Conklin Better Questions).
Avoid Hindsight Bias (he should have, could have etc)
Avoid Confirmation Bias (finding evidence that confirms yours or others’ ideas of what happened)
Avoid Fundamental Attribution Error (Google the term)
For better investigation outcomes, try to include folk who do the work and find out how they do similar work, how the work is arranged what the priorities are and the variability they face when they are doing the work. Facilitate discussions don't investigate and in interview. Don't punish and blame, you can’t do that and learn and improve. Get them (Spvs, workers, managers involved in the operation) in a room for at least an hr talk about the incident, and find out how they do the work, where are the pain points, what rules they break (where are the deviations), why and when do they break them. Every reason is valid even if they don't believe the rules make sense or they are tool complex. Take some time away and let it soak then reconvene to look at solutions.... You will get more out of this than RCA and 5 Whys. then you need to manage the solutions like a MOC project. Keep feeding back to the participants so they can see what actions have been taken and the improvements this helps future engagement.
Work with leadership to change their reaction to failure too this can impact what people are prepared to share bad reactions will obviously dive people away. And try not to wait for an accident to happen, successful work will be riddled with deviations from the plans, review your high risk activities and try this process you might be surprised at what you find
Good article here https://www.nv-reliability.com/single-post/2017/07/03/Introduction-to-the-New-View-Safety2-Safety-Differently
Podcast from Todd http://preaccidentpodcast.podbean.com/
Good Information from Ivan here http://www.safetydifferently.com/understanding-and-adding-to-the-investigation-toolbox/
Edited by user 29 November 2017 09:59:40(UTC)
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