About the Course
“A ship in harbour is safe, but that is not what ships are built for.”
– William G.T. Shedd
For many years Dr Graham Edkins has worked with organisations in developing incident management systems, skilling staff in internationally regarded incident investigation methodologies, and conducting independent safety investigations into fatalities, major injuries, environmental harm, high potential and production loss events across a range of high risk industries and cultural backgrounds.
From this experience, Dr Edkins has a unique understanding of the specific competencies required of incident investigators and how best to develop and sustain these competencies in organisations that operate in fast paced, challenging environments. While, the vast majority of organisations have adopted systemic incident analysis methods in line with international standards, there remains a distinct variability in the quality and robustness of the investigation analysis for several reasons:
- Not all organisations have a clearly defined risk-based approach to classifying safety occurrences and may not investigate to a comprehensive standard;
- Often investigators have difficulty in distinguishing between contributing and non-contributing factors;
- The point at which control is lost is not always well defined, leading to a poor understanding of the efficacy of existing prevention and mitigation critical risk controls;
- The distinction between human failures and latent systemic conditions can be inconsistent because organisations’ do not provide a well defined and structured list of contributing factor types; and
- Because contributing factor types are not always clearly defined, there are lost opportunities to identify repeat failure trends from which to direct more strategic accident prevention activities.
Key Learning Objectives
Upon completion of this course, you will be able to:
- Plan and prepare to conduct safety incident investigations based on specific risk criteria
- Identify a structured human factors approach to witness interviewing
- Clearly distinguish between contributing and non-contributing factors via a practical data collection checklist
- Develop a timeline of events and conditions to provide logic to the analysis
- Recognise the human factor contribution to safety incidents in complex circumstances
- Effectively determine contributing factor types to aid in system wide trend analysis
- Identify practical and reasonable improvement opportunities and key learnings
- Produce quality incident investigation reports based on a highly structured repeatable format
Who Will Benefit
This program is designed for those individuals with some experience in incident investigation or for those accountable managers responsible for reviewing the quality of incident investigation reports. This advanced incident investigation and analysis program will provide participants with a more structured, repeatable and transparent approach to conducting more effective investigations, consistent with international standards and to compliment organisational zero harm target objectives. This course is beneficial to the following personnel:
- Legal experts and government officials involved in investigation-related matters
- Safety Investigators/Auditors
- Safety Regulators
- Those responsible for Safety Information Analysis
- Human Resource Managers
- General and line managers
- Environmental managers
- WHS and injury management personnel
Dr Graham Edkins
Organisational Psychologist Dr Graham Edkins is considered one of Australia’s leading Safety Management and Human Factors experts and is regularly retained as an independent safety investigator and human factors expert witness for various civil and criminal matters.
As a former Transport Safety Investigator with the ATSB, Manager Human Factors for Qantas Airways, Executive Director of Public Transport Safety Victoria, and Group General Manager for CASA, he brings a wealth of experience and detailed knowledge of contemporary safety regulation, major event investigation and human error management practices.
Dr Edkins has represented both the Victorian and Commonwealth Governments on a number of national forums, including the Standing Committee on Transport (SCOT) Rail Group, Vice Chairman, International Air Transport Association (IATA), Human Factors Working Group, Chair National Rail Safety Regulators Panel and the National Steering Committee for the development of National Rail Model Safety Legislation.
He has successfully designed and delivered customised rail safety investigation and human factors management training programs globally to a variety of public and private sector organisations and cultures.
“Very satisfied with workshop. Really learned a lot and looking forward to apply it if needed”.
Senior Executive Bus Safety, SBS Transit, Singapore
“A highly practical and repeatable process that encourages consistency in event investigation”
Investigator/Auditor, Energy Queensland
“Instructor has good practical knowledge of incident investigations”
Safety Manager, Civil Aviation Authority, Nepal
Benefits Of Learning Online
Informa Corporate Learning’s online courses are new digital, interactive and engaging educational experience designed to maximise learning for professionals with busy schedules and/or small training budgets.
Our online courses are perfect opportunity for busy professionals as they require just 2 hours per week of your time and include an interactive forum for you to ask direct questions about challenges you are facing to expert course leaders.
Modules are released on a weekly basis, so you can pace yourself alongside your peers and you will have access to a comprehensive set of assets to support your learning such as video content, quizzes and case studies.
WEBINAR: Improving The Quality Of Significant Workplace Incident Investigation Analysis
Our expert course instructor Dr Graham Edkins delivered a webinar on the need for strategies for improving the quality of significant workplace incident investigation analysis and addressing the pre-occupation with the search for a set of overly broad latent failures.
WEEK 1 – INTRODUCTION TO INCIDENT INVESTIGATION
- Incident investigation and its relationship to WHS management system requirements
- Distinguishing between hazards, near misses, incidents and accidents
- What ‘triggers’ an incident investigation – identifying the level of risk
- Different types of investigation (regulatory, company and legal) and their purpose
- People versus systemic approaches to incident investigation
WEEK 2 – INTRODUCTION TO HUMAN FACTORS AND HUMAN ERROR
- Human factors in context
- A systems model of human factors – the Optimum Human Work Performance Model (OHWP)
- Understanding human error types, causes and consequences
- Organisational error management strategies and the role of error tolerant systems
- Practical error and violation remedy checklist for investigators and auditors
Activity: Identify the error type.
WEEK 3 – A HUMAN FACTORS ANALYSIS METHOD FOR INCIDENT INVESTIGATION
- Critical Review of Human factors analysis methods
- Errors and error producing conditions
- The role of Critical Control Management (CCM) in identifying prevention and mitigation critical risk controls
- The Loss of Control Analysis (LOCA) model for assessing the efficacy of critical risk controls
- Case Study: Application of LOCA to a significant safety incident.
WEEK 4 – INITIAL INCIDENT RESPONSE ACTIONS AND PLANNING FOR THE INVESTIGATION
- Immediate actions
- Securing the site and controlling the hazards
- Notifying relevant authorities and internal managers
- Reporting requirements and WHS legislative obligations
- Completing a notification report – a suggested format
- Incident investigation planning considerations.
Activity: Completion of a incident notification report
WEEK 5 – FINDING FACTS – PART 1
- Introduction to ‘FOCAR’ (to focus on a problem) – A 5 step approach to incident investigation: Find Facts, Organise Data, Contributing Factors, Agreed Actions & Report
- Step 1: Finding the facts via a structured data collection method
- Asking the right question using the OHWP model checklist
- Case Study: Example data collection process
Activity: Brainstorming data sources using the OHWP checklist
WEEK 6 – FINDING FACTS PART 2 – WITNESS INTERVIEWING
- A structured approach to witness interviewing
- Progressive interview questioning techniques, probing and behavioural cues
- Dealing with reluctant witnesses
- Documenting the discussion: Example witness interview template
- Example interview
Activity: Interview assessment
WEEK 7 – ORGANISE DATA VIA A TIMELINE
- Determining the incident and loss of control point
- Identifying post incident events
- Identifying pre-incident events
- Identifying conditions
Activity: Timeline practice.
WEEK 8 – CONTRIBUTING FACTORS
- Identifying Contributing and Non Contributing factors from data collection
- The rule of 3 to determine voracity of evidence – triangulation
- Application of the Loss of Control Analysis (LOCA) model for assessing the efficacy of critical risk controls
Activity: Analysing data and application of LOCA to identify contributing factors
WEEK 9 – AGREED ACTIONS
- How to develop reasonable agreed actions using the SMARTER principle
- Applying the hierarchy of controls
- Strategies to get your corrective actions accepted
- Developing Key Learning’s
Activity: Identifying Agreed Actions and Key Learning’s
WEEK 10 – REPORT AND DOCUMENT
- How to develop structured, logical and quality assured incident investigation reports
- Recommended investigation report structure
- Language and readability
- Example Incident Investigation Report templates based on incident severity
Activity: Incident investigation report writing
WEEK 11 – ACCOUNTABILITY AND CONSEQUENCE MANAGEMENT
- No Blame, Accountability and Fair and Just Culture
- Determining the level of accountability – the notion of intention
Activity: Finalisation and submission of investigation report for assessment
On-site & in-house training
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