EESS Day 1 - Justin Ludcke
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This document discusses foundational concepts for effective incident investigations. It argues that not everyone can investigate incidents well just by following basic procedures and training. Effective investigations require understanding key concepts like using appropriate terminology and models. The presentation contrasts egocentric models that focus on failure and human error with ergonomic models that examine all factors contributing to an interaction. The goal of investigation is to change the future by identifying controls, not blame. Effective investigations account for human, equipment and environmental capabilities to find engineering solutions rather than just fixing failures.
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EESS Day 1 - Justin Ludcke
- 1. Incident Investigation – Back to Basics 7 November 2018 Dr Justin Ludcke
- 2. There is a strong belief in industry that “ anyone” can investigate an incident. While this may be technically true, not everyone can do it well. The " good" companies develop a procedure or have a system and provide some training in a process. This is useful. However, it is often not sufficient to promote effective outcomes from incident investigations to prevent future re-occurrence of the incident. We need to get “ Back to basics” for incident investigation. This presentation will provide some of the foundational concepts that underpin effective incident investigations. These foundational concepts have been applied by InterSafe in nearly 15,000 incident investigations involving non-fatal permanent damage or fatality outcomes, to produce effective controls for the future. Abstract
- 3. Question… What is the purpose of Incident Investigation?
- 4. Our Purpose 1. Understand the incident sequence, in detail. 2. Identify recommendations that will: – prevent the damage, or – reduce the extent of damage (i.e. ‘mitigating controls’).
- 5. Change the Future The purpose of Incident Investigation is to Change the Future.
- 6. The 8Steps™
- 8. 1. Convey meaning 2. Have affect Foundational Concept – Words are Tools “ affect” - to act on the emotions “ effect” - something brought about by an agent/action
- 9. – Failure – Safe / Unsafe act – Safe / Unsafe condition – Fault – Human error – Omissions, lapses, mistakes, violations – Blame – Careless – Negligent Words – Meaning & Affect Common Terminology of Investigation Models No matter how well we try to define these terms… value judgments are required Does this help our insight? Or, hinder our insight?
- 10. What is a “ Value” ? What is a “ Value Judgement” ?
- 11. Values • Love • Trust • Courage • Honesty • Respect • Fairness Values displayed positively promote social cohesion Values displayed negatively promote social disruption
- 12. Interpretation Lens Observation Love Trust Courage Honesty Respect Fairness + - + - + - + - + - + - Lens
- 14. Foundational Concept - Models • What do we mean by the term ‘Model’? • ‘Model’ – A Conceptual Frame of Reference guiding one’s thinking and observations • Examples – Physical, mental, schematic, mathematical etc. The test of a good model is… how close it gets you to your goals.
- 15. Types of Models • Incident and Investigation Models can be: – Egocentric – Ergonomic
- 16. 1. Egocentric – 88:10:2 – Failure / Unsafe focus – Human error focus – Cause of Failure focus 2. Ergonomic – 100:100:100 – “ IS” thinking focus – Contribution to interaction – Control of Future focus Egocentric vs. Ergonomic The test of a model is the extent to which it helps you achieve your goals – its “ usefulness”
- 17. Summary
- 18. Models – IS / IS NOT vs Cause / Effect
- 19. “ Cause/effect” Thinking “ Ideal” Courtship Sequence
- 22. • Origin of model? • Heinrich – Failure model – An incident is the result of a failure • Human failing, Equipment failing, Act of God • More recently – system failure (failed defences) – Find the failure and fix it! • Hence 88:10:2 Models – 88:10:2 vs 100:100:100
- 23. The only scientifically acceptable statement about the involvement of People, Equipment and Environment is: • 100% of incidents have people factors (behaviour, knowledge, skill of people) • 100% of incidents have equipment factors (design features of equipment) • 100% of incidents have environment factors (features of the environment) 100:100:100
- 24. • Failure model • Unsafe acts model • Failure or unsafe is a value judgement! • ASSUMESTHEFAILUREISCAUSATIVE! Sometimes the most effective solution can be: • Not fixing the failure • In the area judged as ‘Safe’ by an investigator Usefulness These models are only useful if fixing the point of failure / unsafe act is an effective solution
- 25. Carbonated Drink
- 26. Tractors
- 27. A defined access system to the tractor Tractor Access – Good Design Features
- 34. Capability of the Human Being
- 35. Capability of the Human Being
- 36. Summary “ To say that accidents are due to human failing is not so much untrue as unhelpful. It does not lead to any constructive action.” T. Kletz (1985) An Engineer’s View of Human Error
- 37. • Understand the purpose • Get the mindset right • Choose the appropriate model to match the purpose • Understand the capability of the human being • Look for the engineering solution Final Points
- 38. Questions? w w w .intersafe.com.au Thank you for your attention