One of the more frequently discussed topics in our workshops is that we can't really understand what we are looking for in terms of the root causes, until we know what causes events. Without that fundamental knowledge, we are likely to fall short of the target.
In the commercial nuclear world, we studied how events happen and came up with a diagram we call "the anatomy of an event." We learned that we have to truly understand the underpinnings of an event before we can establish a comprehensive approach to investigate the event. It should be no surprise that every organization with any level of complexity has hundreds if not thousands of "latent weaknesses" that are causing harm to the organization. When latent weaknesses align in a perfect combination, they will bypass our defenses (the administrative requirements and physical barriers we put in place to stop bad things from happening) and wreak havoc in any number of ways.
Here then, are the parts of the anatomy of an event where we should look for latent weaknesses in order to conduct more thorough investigations:
Human Performance: since humans are not perfect, we have to evaluate what drove any at-risk behaviors that were evident during the event.
Programs, Process, Procedures: in our complex, operating and manufacturing environments, we work to policies and procedures that flow down from regulations and government orders. We know they are not perfect and should be evaluating their effectiveness.
Defenses: every administrative procedure and physical barrier in place that could have or should have prevented the event should be evaluated. I do an analysis of defenses each and every time.
Equipment/Tools/Material Interfaces: how we interface and interact with equipment or tools, and the adequacy of the materials used, should be evaluated.
Working Environment: we may not realize it, but there are a great number of external factors that cause us to change our behavior from one moment to the next. These "error-likely-situations" are created by the working environment and include such things as time pressure, task overload and others. We need to find and evaluate them.
Management / Oversight: management control systems and oversight programs are also defenses in place to keep things running smoothly and we should evaluate their effectiveness.
If we are experiencing recurring events, we should also evaluate the effectiveness of the corrective action programs at our facilities.
Tip of the Week:
By studying the anatomy of an event, we will better understand where to look for latent weaknesses. If we treat each investigation as an opportunity to identify and address as many of these latent weaknesses as possible, we should see a reduction in incident rates at our places of business.
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