Accident Investigation Masterclass

This section begins by introducing and defining the concept of an “incident” and some reasons why we should investigate incidents. It also establishes for the delegates what investigations are/are not about. Key stages to the investigation process are introduced in brief detail here, to be covered by the remainder of the course in more detail.

This section introduces delegates to the broad topic of human factors, indicating the type of features that exist within companies, where the design of the system can affect human reliability for the better of worse. This is the basis of Just Culture, where understanding that sub-optimal design will inevitably encourage human errors and/or violations is important to identify which human factors influenced the incident.

This section teaches delegates about the practical step necessary to ensure accurate collection of evidence from the scene of the incident. The level of detail required will vary depending on the nature of the incident, but there are key steps and concepts to follow for all incidents. The importance of keeping an open mind at this stage is emphasised and avoiding the temptation to make the evidence fit any expectations that you may have. As part of the evidence collection process, technique for conducting witness interviews is covered in considerable detail.

Once the evidence has been collected, an investigator/ team must be able to objectively analyse the information to determine what happened. This section covers key techniques (e.g. task analysis; ABC analysis; 5 whys and others) which can assist in a logical and objective breakdown and organisation of the facts to understand what went wrong and therefore the best way to correct it. The techniques will teach delegates about determination of immediate and root causes. This should reveal which parts of the company systems (e.g. communications, procedures, equipment and so on) could have influenced behaviours and under the philosophy of Just Culture, the best course of corrective action.

This section covers how to make practical and effective recommendations in a clear and transparent manner, linking them logically to the immediate and root causes of the incident, not simply apportioning blame and administering discipline when system issues are the issue.

Once the incident has been adequately investigated and analysed, all the information must be carefully and logically recorded in a report, which finishes with recommendations which can be traced directly to the immediate and root cause(s).

Delegates will learn that once the investigation is complete and the report has been written and agreed, feedback should be provided to the personnel directly involved. The pros and cons of different methods and styles of feedback will be discussed here and the need to maintain confidentiality during the feedback.

Once the delegates have learned the theory of conducting investigation they will work through the steps using a safe example. This practical experience throws up questions that may not have occurred during the theory and helps the delegates to gain confidence in their ability before applying their new knowledge back at base.