Introduction
This article explores the customisation of a standard process by an organisation and the impact it has on the fundamental principles of the process, and whether the customisation enhances or diminishes the effectiveness of the process.
As an organisation strives for operational excellence by looking to improve upon its systems and processes, the organisation typically associates itself with leading industry initiatives and searches for an existing and proven process, as opposed to undertaking the time-consuming development of an in-house method. Most often this is achieved through research and consultation by looking at other users’ experiences, challenges, benefits, acceptance, appraisals, and recommendations on the process to enable an informed decision regarding applying the process methodology within their business. Put simply, looking to utilise existing industry best practices to demonstrate effective and quality outcomes within their operations.
The Merriam-Webster Dictionary defines ‘best practice’ being “a procedure that has been shown by research and experience to produce optimal results and that is established or proposed as a standard suitable for widespread adoption.”
Too often, though, there are instances where an organisation may need to modify that process to customise to meet specific internal requirements. While this has good merit, the question we must ask ourselves is; “have we over-complicated the process by adding redundant elements and unintentionally compromising the application and fundamental principles of the original process?”
In this article, the process being put to the above question is the “incident investigation methodology” used for a system-level investigation of a workplace incident.
The System-level Incident Investigation Process
A system-level incident investigation examines the contributing factors to an incident, with the focus being on identifying latent systemic health, safety and environmental deficiencies within the organisation’s systems and processes. Additionally, the investigation includes both cultural and behavioural aspects which may impact the operational discipline to the application of process, which may or may not, have contributed to the incident.
The Incident Cause Analysis Method (ICAM) is a system-level incident investigation methodology and is a leading causation investigation model widely recognised across industries.
The methodology of ICAM consists of four core stages which underpin the fundamentals of an investigation of asking key questions of ‘Who, What, When, Where, Why and How.’ The four stages of investigation include:
1. Data Gathering
2. Data Organisation
3. Data Analysis
4. Recommended Corrective Actions
Each stage is designed to play a specific part in the investigation process, with each stage dependent on the other for an effective and quality outcome providing the desired result. This design allows the process to be intuitive and demands a check-based approach from one stage to the next to deliver repeatable results between various investigators.
This methodology is designed to overlay the many organisation investigation procedures being used across a wide variety of industries. Each industry organisation customises the ICAM to align with its needs. This is important as each industry does have its unique characteristics; however, have we sometimes been over-zealous in creating in-house modifications and (so-called) ‘improvements’ that can be counter-productive with redundant elements, thus unintentionally creating inconsistency in quality between investigations and investigators?
Let us examine these customised modifications and determine if they are adding value by being smarter or if these additions or exclusions erode the fundamental principles compromising an effective investigation. Firstly, we should unpack the four core stages of the investigation methodology into their basic elements and consider the impact on the investigation process by the common additions and exclusions currently adopted by some organisations.
Data Gathering
The ICAM uses the simple and effective ‘PEEPO’ technique covering the five data sources for gathering information which consists of:
1. People
2. Environment
3. Equipment
4. Procedures
5. Organisation
The application of the ‘PEEPO’ is composed of two separate parts to gather the data. These parts being ‘PEEPO Mark1’ and ‘PEEPO Mark2.’
PEEPO Mark1 - Plan for what you are going to collect. This is based on limited information about the incident, where the investigation team comes together and brainstorms the data sources for the information required.
This is the pre-gathering planning. It is essential that the investigator initially spends a short amount of time brainstorming what data to gather and the various sources for gathering that data. Basically, there are four questions to ask during this planning step:
· What was the task?
· What is the Safe System of Work (industry benchmarks for safe execution) for the task?
· How was the task actually performed?
· What are possible organisational and environmental conditions that could adversely affect how the task was performed?
This step develops the plan to gather data which is critical for efficiency and effectiveness, laying the foundation for the overall investigation.
About the Author:
Bruce Johnson (Investigator/Trainer)
Bruce's extensive experience covers engineering, organisational development and business improvement with large multifaceted organisations holding senior positions in both the private and government sector.
He has worked in both project management and change management, leading specialist teams to achieve business improvement outcomes within health and safety, maintenance management, role and business restructuring, and learning and development.
Through performing various roles across many industry sectors including manufacturing, construction, oil and gas, energy, mining, transport and dredging, Bruce offers a wealth of knowledge and the practical application of best practice management.
This experience combines to deliver the ICAM incident investigation training and independent investigations to a high standard, keeping ICAM as the benchmark across multiple industries. From the identification of business needs through to the strategic development and implementation of workplace improvement initiatives, Bruce provides a reliable and intergrated WH&S support service.
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