System Root Cause Analysis

Third Party Investigations

Systems Root Cause Analysis (SRCA) Incident Investigations

Third Party Investigations – Using Systems Cause Analysis (RCA) Methodology

Why 3^rd Party Investigations are important:

All incidents / accidents need to be investigated as it’s a legal requirement to determine the level of risk involved as it could have serious implications for the organization, as well as a good business principle practice.

Organisations is required to conduct a Preliminary Incident Investigation by inhouse trained personnel. Depending on the level of risk involved, may conduct a full investigation themselves or require an independent third-party investigation if there are serious consequences or an independent unbiased report is required.

In some situations, the Department of Employment and Labour may require an independent investigation or the Head Offices of large organisations to demonstrate impartiality.

By using an independent incident investigation Facilitator, brings a wealth of experience due to exposure of investigating many incidents across numerous industries.

The process that will be followed:

– Once the proposal for the investigation is accepted.
– The organisation will be asked for the Flash or Preliminary Investigation Report.
– The Facilitator will forward a list of questions and evidence required for the investigation.
– The Facilitator will need to visit the site where the incident occurred to familiarize himself / herself with the environment & circumstances prevailing at the time of incident.
– Eyewitness and witnesses with information statements will be requested. If not recorded as yet the Facilitator will request the relevant witnesses be interviewed and statements taken.
– When the Facilitated investigation starts the process will involve a formal “workshop” style session, facilitated by an experienced facilitator.

– Brief introduction on the Causation Model and systematic Root Cause Analysis.
– Information Confirmation – information will be recorded on flip chart, and the flip charts will be posted on the wall of the room for reference purposes:
– With the information gathering completed, the cause analysis would be initiated. The facilitator would utilise a personal computer and projector to assist in the process, the team would therefore be able to follow the process on the screen.The facilitator will put questions to the team, such as: “Based on the information gathered, did any person at the time of the incident operate without authority?” The question would be posed to the team, and any person would be free to answer.
– The facilitator will prompt the team where he feels a potential cause exists.
– The replies would then be recorded.
-When this process is complete, the Facilitator will further analyse the causes and circumstances, if need be, and request additional information, where required.
-The Facilitator will then compile a draft incident investigation report, which will be Peer Reviewed internally and then forwarded for scrutiny and feedback by management and once agreed upon a final report will be issued.

 The persons that should be involved, should at least be the following:

– Eyewitness / persons with information regarding the incident.
– Knowledgeable persons, which could include:
– Immediate supervisor of the facility – to provide information on inspections, task analysis, group meetings, training, etc.
– Training officer – to provide input in terms of training of the person and training courses.
– Human resources officer – to provide information on the selection and placement system.
– Personnel knowledgeable on completed risk assessments.
– Maintenance people of the equipment involved – to provide information on the maintenance of the equipment and maintenance system.
 – Other persons as may be identified before or during the facilitation workshop.

 Incidents do not just happen – they are caused.  Once a particular incident occurs, it will reoccur – the question is when and how serious will it be next time!