top of page
buncfield image.PNG

Investigation Workshop

"World class organizations do not tolerate preventable accidents"

Don't put a bandage on the problem; fix the issue permanently!  Our course is designed to give the participants an insight in the complexity of accidents and incidents and the methods for prevention and reducing them and their costs.  Our proven methodology is based upon James Reason’s Swiss cheese model and Nobel prize winner Daniel Kahneman's, "Thinking fast and thinking slow".  Combined, a systems approach and the psychology behind our mistakes, your safety system will be resilient to human error. 

James Reason established that there are 4 separate levels of barriers:  Organizational Influences, Supervisory Factors, Preconditions and Unsafe Acts.  These 4 levels of barriers are sequential in nature, meaning that the levels at the top affect the levels below.  Within each level, failures can cause holes in your safety barriers.  These failures/holes can either be active or latent (indirectly contributing to incident). In theory, at least one failure will occur at each level leading to an incident and our model will allow the investigator an opportunity to discover them.  Using our industry leading methodology as a guide, investigators will identify systemic and individual failures (both active and latent).  

Daniel Kahneman defined our errors through the analogy that our brain is comprised of two characters, one that thinks fast (system 1) and one that thinks slow (system 2).  System 1 operates automatically, intuitively and effortlessly.  However, our system 1 is plagued with biases that set us up for mistakes.  System 2 requires slowing down, deliberating, solving problems and does not jump to conclusion.  System 2 is effective at trapping human errors but is prone to channelized attention and distractions. Our proven systematic approach combined with a deep understanding of why we err will aid your team with the ability to develop corrective actions that are preventative.  Below is the course outline:

Day 1:  Attendees will start with an exercise that sets the foundation for the principles of HPI.  Our exercise will highlight organizational failures as well as supervisory failures in an incident.  The afternoon session will cover an interviewing technique that will add 60% more detailed information from a witness.

Day 2:  The morning session will have the attendees dive deep into understanding why we err.  Highlighting the strengths and weaknesses of our decisions. The afternoon session emphasizes a key process called red teaming which improves investigations by 20%.  Once completed, your team will learn the importance of a standardized taxonomy to demonstrate the consistency when finalizing their investigation. Standard taxonomies provide a comprehensive framework for identifying accidents’ causal and contributing factors which will develop data-driven interventions, and objectively evaluate safety trends.

Day 3:  The final day will start with sharing the best practices for writing the report.  Then, the course will wrap up with an accident and the participants using the HPI methodology to determine the cause, contributing causes and appropriate corrective actions to prevent the accident from recurrence.   

Applying a customized developed standardized taxonomy list to the results from an HPI investigation, allows your organization to visualize where in their operating system accidents have occurred.  Furthermore, it highlights the causes and contributing causes so leadership can uncover actionable weaknesses, analyze risk in your current operation, identify new hazards and analyze the effectiveness of your safety controls. 

bottom of page