Learn from the Worker
Finally, in this short series of investigation themed articles, I want to explore how we can seek learning and improvement opportunities before the occurrence of an incident or mishap.
For an incident to occur, all the necessary causal ingredients need to exist and conspire. It’s like the fire triangle…for a fire to exist and survive it needs fuel, oxygen, and an ignition source. Without all three, no fire. On any given day in an organisation many unwanted event causal ingredients or latent factors will exist, however most of the time, thankfully, they don’t conspire, like the fire triangle, to cause an incident.
The swiss cheese model has been around for decades but it remains relevant and reinforces that incidents never have a single silver bullet root cause. I guarantee that today, there will be latent factors lurking unseen or unnoticed in the everyday work of your organisation just waiting for the opportunity to team up and cause harm.
Best to expose them before they get active.
Learn more about HOP.