Table of Contents

Acknowledgments

Preface

What 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

About the Author

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.

Reviews

"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