Forensic Engineers & Investigators
Organisation Accident Investigation
An organisational accident or incident is a failure or deficiency due in part to problems with the system or organisation in which the problem occurs. These types of failures at first glance appear solely due to mistakes or oversight by individuals or single entities. However on deeper analysis, contributing factors from the wider system or organisation become apparent.
Some typical examples of organisational contributors are: Poorly written rules, standards, guidelines, unresolved intercultural factors detrimentally affecting communication between groups of people, changes in corporate practices without corresponding changes in work practices and guidelines, loss of institutional memory as staff with knowledge leave and take their learnt lessons with them, old versus new work habits and practices.
Our investigation tool box refers to two simple causal analogies in uncovering these organisational factors: James Reason’s Swiss cheese analogy and Sydney Decker’s failure drift analogy. The first is useful for showing that multiple causes/contributing factors are the norm and that they conspire together; the second helps to show that many failure steps are needed to cause a problem and these occur incrementally, insidiously and imperceptibly. Applying these principles to the investigation at hand can be very powerful in preventing future accidents and issues. They facilitate great team building opportunities in the aftermath of a painful incident or mistake because they highlight deficiencies in the wider organisation which everyone must help to fix, as opposed to mistakes by individuals, even though these are also noted.
How we do it
The Prosolve process of investigating organisational incidents and accidents is as follows:
Stage 1: Determining the facts. An engineering analysis is completed, followed by a series of comprehensive interviews and documentation reviews. At this stage, a preliminary draft report highlighting significant questions or issues of interest, can be written for management. However this report is very preliminary.
Stage 2: A detailed preliminary draft report collating and summarising the facts is written and distributed to those involved in the incident and who contributed to the fact gathering process. This is the draft review process and is necessary to confirm factual correctness. An analysis section can be written at this stage, but for some incidents, this is better left to the workshop which is the next stage.
Stage 3: A workshop is convened to discuss the factual findings of the report. It is necessary that all stakeholders attend and this can last up to a day. The workshop begins with a presentation portraying two major calamitous case studies utilising the Swiss cheese and failure drift causal analogies. These case studies provide a de-biasing defence against the hindsight bias and show that even the best of us make mistakes. Following this, the report written above – still in draft status, is worked through in discussion, with additional comments and contributions by all attending. The workshop concludes with a summary of discussion findings.
Stage 4: The preliminary draft report is modified to include information discussed and agreed in the workshop above. It may support recommendations which are able to be issued to other stakeholders or parties. A final report can now be issued.
Stage 5: Issue final report.