By Colin Duncan on May 16, 2019 1:36:00 PM
We have made available the recording of our May 16th, 2019 webinar “Reframing Event Analysis – Visual Literacy in Incident Investigation,” presented by Colin Duncan.
• Explore the challenges of effective incident investigation and event analysis.
• Consider how changing the orientation of incident investigation/event analysis can significantly improve the quality of the output.
• Look at the two key ways in which Visual Literacy plays a role in understanding safety incidents – their causes, the incident analysis and the corrective actions that need to be considered.
Incident Investigation is central to an effective safety program but learning from events just isn’t as straightforward as we might like. There are multiple barriers to effective analysis, to accurately identifying the causes of unplanned events – and how to mitigate for the future. Barriers such as time pressure cause rushed investigations and can lead to flawed assessments. Cultural factors such as prevailing assumptions, tendency to seek blame or lack of teamwork and collaboration all play their part. Leadership orientation is pivotal, with leaders too often believing the correct solution is at the worker level rather than taking a systems-based approach.
All these factors undermine an organizations ability to learn from unplanned events – safety incidents, near miss events, spills/releases and serious injuries. But at the heart of these challenges is a little understood dynamic – our ability to accurately see what could happen, what did happen, and why! Our research suggests that up to 24% of incident reports suggest a gap in visual acuity – that is, somewhere in the ‘system’ something was not seen fully, accurately, properly assessed or communicated – and that contributed to the unintended event. Furthermore, safety professionals consistently report that they see the same gaps in the actual ‘investigation’ after the fact.
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