Traditionally many organisations have focused on learning from incidents and accidents to make system improvements. Over time, sources of information for improvements can include close calls, near misses and audit findings. These are all excellent ways to learn about, and improve, the system but what if there was more we could do?
The idea behind pre-accident investigation is to identify areas for improvement before they result in an incident or accident. There are a few different ways of doing this, however the best way is to view safety critical tasks through the various performance shaping factors which exist in every workplace, every day, to pre-emptively assess the error potential. By establishing this likelihood, controls can be assessed and implemented to help avert an incident. While this process will not tell you your next accident, it will improve your safety margins and performance.
By involving the people doing your most safety critical tasks every day, you are able to access useful data on system performance. They are the experts in knowing where the system does and does not work and the ways that people can complete the task outside of the safety of procedures and other controls. In addition to identifying the error potential and various factors which undermine performance, these teams can also learn about how to control these hazards and help to pass this information on to others.
Staff at The Keil Centre have extensive experience in error identification and investigation techniques and can help you and your staff conduct pre-accident investigations. For more information about conducting this process in your organisation, please contact Melanie Todd in Australia or Enquiries in the UK.