“…There is no such thing as chance or accident; the words merely signify our ignorance of some real and immediate cause…”
Adam Clarke
Introduction
After incidents and accidents, most organisations go through some form of review or soul-searching to ask themselves if they could have done things better. The problem with this is that often company staff are too close to the systems to be honest (consciously and unconsciously) and often the phenomena of “industrial blindness” means that they are unable to objectively observe shortcomings or areas for improvement.
Any improvement, or reflection on improvement, needs to occur fairly soon after the incidents or accidents, whilst the memories of the events are still fresh. By bringing in an outside, “disinterested party”, it is possible to collect valuable evidence and intelligence which can be constructively used to make improvements and close any gaps in response and reactivity that may exist in the company’s systems, awareness, procedures, training and response mechanisms.
Process
There are many different processes and routes that can be taken to guide the activities for review. They depend very much upon how much the company is willing to spend and what information it would like to gather. Before costing the review exercise, it is important to have a meeting between the company and the external reviewer:- to establish an outline understanding of the event or occurrence; and define a scope of work and activity. This can then result in a cost effective and optimal proposal which can lead to a useful document for continuous improvement purposes within the company.
Topics to be reviewed
The following pointers are a sample of the topics that should be covered in the review:-
- Cause
Was the cause of the incident covered in the corporate risk assessment, risk policy and or aspects and impact register? Was it covered by the company’s ISO 9001, 14001, OHSAS 18001/ ISO 45001, ISO 31001, ISO 37101, etc. certified or aligned systems?
- Response
Was there a response plan based upon the scenarios developed in the planning of the emergency response plan/policy/procedure?
- Response Team
Was the response team adequately briefed and trained to deal with the incident? Is there an effective succession plan in place to cover temporary or permanent absences of key management and technical staff in the response plan?
- Communication
Was communication to identified and appropriate stakeholders on the incident spelled out in a communication strategy/procedure, including who to communicate with, what to say to them and how to maintain the dialogue? Was anyone tasked to track and file media coverage of the incident and feedback strategic content to the response team and or senior management?
- Decision-making
Was there a structure in place to ensure that any necessary high level decision could be taken, passed down to the response teams and communicated to stakeholders and the media timeously?
- Record keeping
Was there a mechanism is place to ensure that key information from the incident, as it unfolded, was fully recorded, documented and circulated to pre-identified key decision making individuals?
- Incident Investigation
Was there a multi-dimensional incident investigation process/procedure in place to commence investigating cause and effect as soon as possible?
- Training
Were staff sufficiently trained and empowered to deal quickly with the incident and minimise the damage/loss/cost? Could hesitation or delay be put down to lack of confidence due to inadequate training, exercising or sequential tasks steps?
- Procedures
Are there procedures in place to respond to the incident? If so, were they successful? If not, why not and what was used in their place?
- Recurrence
Is the incident isolated or could it occur again in the same, or similar, form elsewhere in the company?
Concluding Thoughts
The passing of time generally means that it is very difficult to completely “undo” the consequences of accidents and incidents. If it is possible, this may take a long time and may cost considerable resources.
It is crucial to look forward and learn from the experience, good or bad. Fobbing off the incident as “a freak chance” or “not likely to happen again” is not constructive. Minimising the possibility of recurrence requires careful deliberate investigation, root cause identification and modification and change of systems procedures, training and preparedness. It may even require the implementation of a change management process to test options and alternatives.
Arend Hoogervorst
EMS Auditor
Eagle Environmental