Simplicity in Safety Investigations

Acknowledgments Preface What level of investigation should we do? Using this book and the techniques described within it for positive investigations Some essentials Part I - Mindset and approach Part II - Before you investigate Team formation, structure and roles The art of facilitation and using a coaching style Your conversations and questions (before and after an event) Part III - The investigation process Scene preservation. Interviewing (versus taking statements) Generous listening The interview conversation Data and information gathering How to run an effective and efficient PEEPO Determining Work-As-Done, Work-As-Normal and Work-As-Intended Determining Work-As-Done, Work-As-Normal and Work-As-Intended in the case of more detailed incident investigations Exploration of the gaps between Work-As-Done, Work-As-Normal and Work-As-Intended Build the story (Incident Pathway Statement) SMARTS actions Reports Part IV - The technical and scientific stuff Task complexity, procedural complexity and adequacy, and situational complexity Resilience and resilience engineering Risk intelligence, risk identification and risk management Drift (procedural or practical drift) Internal decision and sense-making Intense task focus Answering a different question What-You-See-Is-All-There-Is (WYSIATI) and plan continuation Shared Space as it relates To safe work spaces Effective 'core competency training' and 'awareness induction' Individual actions and assessments Systems of work and their interrelationships It is all obvious when you know the outcome (hindsight bias) Accountability and authority mismatch Equipment, tools and plant design Task planning, assignment, acceptance and monitoring Leadership Other cognitive biases and heuristics The efficiency - thoroughness trade-off (ETTO) Part V - Conclusion Appendices: A. Interviewing - Having meaningful conversations B. Incident Cause Analysis Method (ICAM) process Bibliography and reading list. Index