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Behavior-Based Incident Analysis

(Accident Investigation Redesign)

Article: Beyond Observation & Feedback: Integrating behavioral safety principles into other safety management systems (pdf)

Thorough and effective analyses of workplace incidents are critical components of a comprehensive safety management system. Yet, many Incident Analysis processes (i.e., accident investigations) fall short. They frequently fail to identify and resolve the real root causes of injuries, process incidents, and near misses. Because the true root causes of incidents are within the system, the system must change to prevent the incident from happening again.

Further, because employees’ perceptions of incident analyses are often negative, individuals are often reluctant to report incidents and participate in the analysis for fear of reprisal or because they believe little improvement will result.   How do we get the information we need? Why don’t employees report? How do we get employees to openly participate in the analysis process?

While one goal of an incident analysis process is to determine the immediate causes and root causes that allowed the incident to occur (so effective countermeasures can be taken to reduce future injury risk), there’s a second, equally important goal. The incident analysis process must also encourage full and open participation of employees by eliminating a fault-finding adversarial atmosphere so often surrounding the process.   Organizations must let go of outdated ideas on how to deal with mistakes caused by human error and calculated risks.   SPS teaches organizations how to reach both goals.   In particular, SPS teaches organizations how to identify system influences on risky behavior and human error and how to involve employees in conducting an open and honest exchange of information regarding incidents.

How Can SPS Help?

To address these concerns, Safety Performance Solutions offers three levels of service:

  1. Full Redesign Support
    SPS conducts a four-step analysis and redesign of the organization’s incident analysis process followed by training and evaluation.
  2. Two Day Workshop
    SPS conducts a two-day workshop for both experienced and novice participants familiar with basic incident analysis procedures.
  3. One Day Workshop
    SPS conducts a one-day workshop which is a reduced version of the two-day workshop.

Article: Beyond Observation & Feedback: Integrating behavioral safety principles into other safety management systems

Behavior-Based Incident Analysis: Full Redesign Support

SPS assists organizations assess, modify, and evaluate their incident analysis process.   The typical approach involves four steps:

  1. Situation Appraisal and Planning. SPS personnel gather background data concerning the current incident analysis process.   This includes reviewing documentation as well as surveying and/or interviewing representative employees.
  2. Process Development . Based on the information gathered in Step 1, SPS works with site personnel to develop revised investigation procedures and tools.   The new process is documented in a “guidebook” for use by the incident analysis teams.
  3. Training . A training course is customized and delivered for prospective members of the organization’s analysis teams.   This course is typically a two-day course similar to the one described in Level Two Support: Two Day Workshop.
  4. Process Implementation and Follow-Up Coaching . During the early stages of implementation, SPS will review the results of 2-3 analyses to provide feedback on the use of the new processes and tools.   Following each analysis, SPS will administer a short survey soliciting feedback from the participants.   After 6-12 months, SPS will repeat the survey/interview process conducted in Step One.

Behavior-Based Incident Analysis: Two Day Workshop

This two-day workshop is designed for both experienced and novice participants familiar with basic incident analysis procedures. In this workshop, participants learn to go beyond the conclusion that the incident resulted from simple human error. Instead, they learn how to identify the root causes of human performance deficiencies enabling them to reduce systematically the motivation for risk taking behavior and the varied causes of human error. Through the use of case studies and hands-on exercises, participants apply an investigation philosophy of “fix the system” not “blame the injured employee”.

This is not a "how-to" course on traditional incident analysis skills such as physical evidence collection and preservation or use of analytical tools (e.g., cause and effect diagramming, multi-linear event sequencing, or Management Oversight Risk Tree). Rather, this two-day workshop provides an in-depth look at how employees’ performance and safety-related behavior is influenced by the organizational culture and the physical work environment.

Specifically, participants will learn:

  • Practical applications of theories of human motivation, human information processing and human error to incident analysis and development of appropriate countermeasures.
  • How human behavior is influenced by management systems including training, supervision, organizational reward structures, and communication systems.
  • How technology, including human-machine interface design and the design and use of operating procedures, influences human error.
  • How to identify and prevent repeated human error or error-producing situations.
  • How work environments encourages risk-taking behaviors in the workplace.
  • Witness interviewing techniques to foster disclosure and enhance memory of events.

After attending the workshop, participants will be able to:

  • Conduct incident analyses to better identify not only immediate causes but multiple root causes including organizational system failures and human performance deficiencies.
  • Develop and implement effective countermeasures to prevent future incidents.
  • Foster an environment of fact finding to encourage employee participation in incident reporting, analyses, and remediation.

Includes: Two-Day Workshop Manual and Suggested Reading List

Incident Reporting and Analysis Process: One Day Workshop

SPS conducts a one-day workshop which is a reduced version of the two-day workshop.   Often the senior managers attend the two-day version and then the one-day is provided for front line supervisors and others participating more directly in the analyses process.  

To review the two day course content, see Two Day Workshop above .

Related Links

SPS offers a variety of services critical to achieving a Total Safety Culture:

  1. Safety Culture Assessment
  2. RADAR Data Management
  3. People Based Safety Process
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