An organization’s incident investigation process says a lot about its safety maturity

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Taking from the “Five Themes for Excellence in Safety Management Systems (SMS)”, we can look at a facility’s incident investigation process through this lens of excellence and measure the maturity of the safety culture.  To recap the progression, here are the five levels:

  1. Ad-Hoc
  2. Managed
  3. Standardized
  4. Predictable
  5. Excellence

Using an organization’s incident investigation process, we can see where they lie on the path to SMS Excellence.

 

Ad-Hoc – Evidence of a blame culture when something happens

  1. There is no evidence of effective investigations, and the organization’s culture is to find someone to BLAME.
  2. Employees do NOT believe it safe to speak up and, therefore, tend to COVER UP GENUINE ERRORS.
  3. The organization focuses on the actions of the individuals RATHER THAN LOOKING TO CHALLENGE THE ADEQUACY OF SYSTEMS AND RISK CONTROLS.
  4. No training in investigation techniques, no independent investigators.
  5. No joint investigations of incidents during collaborative ventures.

 

Managed – Culture is to accept inconsistencies in investigations and superficial recommendations which do not improve risk management

  1. Incidents are investigated, but only where the organization’s guidance directs. The investigation process followed is not proportionate to the risk.
  2. Frequently, only immediate causes are identified and investigated.
  3. The range of incidents investigated is LIMITED TO ACCIDENTS.
  4. Recommendations are limited to preventing the same thing at the same location from happening again. They do not identify areas for broader improvement.
  5. Investigations are carried out only by safety professionals and managers who are not independent of the incident.
  6. Inconsistent use of investigations during collaborations.
  7. Confidential incident reporting is embedded in the investigation process.

 

Standardized – general understanding of the importance of quality investigations into a range of occurrences generating recommendations that improve systematic control of risks

  1. The defined management arrangements for when and how investigations are carried out are followed consistently across the organization.
  2. The underlying causes of an incident are identified and investigated. Investigations are also carried out after a near miss or near hit and H&S complaints.
  3. The investigation team selected is proportionate to the type and severity of the matter under investigation.
  4. Employee representatives participate in the investigation.
  5. There are systems in place to ensure that the competence of investigators is maintained.
  6. The investigation procedures include collaborative working and the need to investigate reports of non-compliance, non-conformance, near miss / hit reports and H&S complaints.
  7. Human factors and human performance are considered as part of the investigation and the training for investigators.

 

Predictable – Investigations and recommendations arising from them are generally accepted as ESSENTIAL WAYS OF IMPROVING RISK MANAGEMENT

  1. The quality of investigation produces recommendations that can be applied across the entire organization.
  2. The range of incidents investigated includes, where appropriate,
    • non-compliance,
    • non-conformance,
    • near miss/hit reports, and
    • health and safety (H&S) complaints or disruptions to work and where expected outcomes are not achieved.
  3. Investigations produce recommendations that can be applied across the organisation and relevance outside the organisation is routinely considered as is the impact of the recommendations on risk management.
  4. Employee representatives, including, where appropriate, trades union safety representatives, are actively involved in investigations.
  5. The effects of recommendations from investigations on risk control in collaborative working are themselves reviewed to demonstrate improvements in
    risk control.

 

Excellence – There is a ‘just’ organizational culture where all employees openly and honestly participate in the investigation. All employees see Incident investigation as an opportunity to deliver CONTINUOUS IMPROVEMENT, and managers respond fairly

  1. The organization actively seeks to implement findings from EXTERNAL investigations to support continuous improvement.
  2. Managers and board members have objectives to review reports of external investigations from the industry and other sectors to identify opportunities for CONTINUOUS IMPROVEMENT.
  3. Relevant investigation outcomes are routinely shared within and outside of the organization.
  4. Board members and executive leadership actively promote and support the development of techniques and training for investigations.
  5. Collaborative working incidents are investigated to learn lessons that aid continuous improvement.

 

 Source: RM3, 2019 – The Risk Management Maturity Model (UK’s HSE)

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