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Explaining the process
If you start a journey aiming in the wrong direction, it doesn't matter how fast you travel, you will never reach your destination. Thats why the new kick off meeting is so important. This short meeting formalises the team, the timeline, the rules and the critical factors to focus on. This ensures structure to the investigation so you only investigate causes relevant to the incident and not peripheral issues. It also focuses the team to deliver to a tight deadline and to think of quality instead of quantiy of information and findings. |
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The phrase, 'a centimetre wide and kilometre deep' is key to a good investigation. By narrowing the breadth of the investigation you can focus on the depth; keep asking why each cause happened and then what led to that cause also happening, until you find the management or cultural causes of the incident. We call them the immediate, underlying and latent reasons. Only by solving the latent reasons and then spreading the learning to everyone else can we ever hope to reduce our incidents and injuries in the PDO operation, particularly our contractor and sub contractor community. |
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The final learning value change is in ensuring quality at each stage of the investigation. This is why the MSE3, MSE4 and MCOH team provide support and advice to all serious incident investigations relevent to their subject and the incident Owner can call upon designated experts in technical fields to join their investigation teams. By assuring the quality, direction and depth of the investigation in small meetings throughout the investigation it saves much time and effort correcting mistakes late on in the process. Never lose sight of the fact that we investigate to learn, we learn to avoid future incidents and losses. |
