VPPPA Conference Notes

Title

Improve Incident Investigation Effectiveness

Presenter

Stan Owens (Behavioral Science Technology)

Session Date

September, 2003

Take Aways

• Accident Ice-burg:
• Seen
• Fatality,
• Lost time,
• Recordable,
• Property damage
• Unseen
• Exposures,
• At-risk behaviors


• Barriers to safe performance
• Hazard recognition & response
• Business systems
• Rewards & recognition
• Facilities & equipment
• Disagreement on safe practice
• Personal factors
• Culture
• Etc.

• People are afraid to talk with investigators. Public perception of an investigator is someone who investigates criminals, gathers evidence, which leads to; a trial, conviction and punishment.

• Behavioral Incident Investigation;
  • Determine what happened,
  • Root cause analysis
    • Why it happened
• Make changes, replace

• Improve consequences, since consequences may hide truth/facts from being reported

• Feedback is a consequence
• Safe behavior/good consequences
• At risk behavior/bad consequences
• Use data to identify barriers, and then remove barriers to safety. This is critical to any organizations success in safety improvement.
• ABC Analysis
  • Antecedents - precedes or triggers behavior, only to the extent that they predict consequences
  • Behavior – an observable act
  • Consequences – anything directly following behavior, consequences control behavior. Three factors affect consequences;
    • Timing – sooner/later
    • Consistency – certain/uncertain
    • Significance – positive/negative
• Ideal Safety Culture
  • Role of Senior Leadership – set a vision
  • Role of Managers and Supervisors – Understand vision, skills to support vision
  • Comprehensive employee engagement
• Rx for failure
  • Jump too quickly to solutions/”why”
  • Place fault or blame
  • Stop with just one cause
  • Don’t construct a behavioral sequence of events
  • Ignore possible barriers

Session Worthwhile for Future Attendees/Meetings

Yes

Recommended Actions for Evaluation by VPP Steering Committee

Accident Investigation subcommittee has heard comments from staff that the Incident critique process can be intimindating. PNNL should evaluate the overall process in order to combat the perceived threat. The incident critique process should be seen as a learning tool, not a blame maker.

Review provided by Mike Tinker