PrefaceWhat level of investigation should we do? Using this book and the techniques described within it for positive investigations Some essentials 1 Mindset and approach 2 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) 3 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 4 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) 5 Conclusion Appendices: A. Interviewing - Having meaningful conversations B. Incident Cause Analysis Method (ICAM) process Bibliography and reading list.Index
Ian Long has worked for over twenty years in Health and Safety roles in the minerals extraction and processing industry. As the managing director of his own consultancy business, he now provides in-the-field coaching and coach-the-coach activities with leaders, along with training and facilitation of fatality and other significant incident investigations.
"This is not a big book, but it packs a lot of ideas into 142 pages. The author, now a consultant but formerly in a senior OSH post at Australian miner and nickel refiner BHP Billiton, has a lot of experience to draw on but he is also clearly well read. One of the strengths of this book is how he harnesses theories from writers such as Todd Conklin and Daniel Kahneman to the service of accident analysis."
Stephen Marriot, IOSH Magazine