A Human-Centered, Learning-Focused Approach to Incident Investigation
Every safety program includes a process for investigating incidents. What often happens, though, is that for a number of reasons these investigations fall short of yielding actionable insights or helping reduce exposure organization-wide.
Event Learning is an enhanced approach to incident investigation aimed specifically at enabling the organization to learn from the incident and apply that learning systemically. Both practical and holistic, Event Learning helps you:
- Balance system and culture causes with human performance causes to provide a more complete picture of why the event occurred.
- Extend the investigation results beyond identifying causes and applying spot corrections, to taking a Learning Organization approach to prevent future occurrences and reduce overall exposure.
Who can benefit from it?
Event Learning is ideal for companies of any size in any industry that want to:
- Eliminate, reduce, or control exposure to injury across the organization.
- Modernize their investigation approach to incorporate the latest thinking and methodology to understand and maximize human performance.
- Advance their ongoing journey as a Learning Organization.
- Ultimately increase the return on their investigation’s investment—and potentially lower that investment by avoiding incidents.
How does it work?
Comprehensive and holistic, Event Learning looks at five critical categories that drive the causes of exposure:
1. Climate, Culture, and Leadership. How is work done, and who is successful? What gets rewarded? What happens when there is a conflict between production expectations and safety expectations?
2. Systems and Processes. How do the procedures for work and the systems that govern work and safety align with reducing exposure or make it more difficult to work safely?
3. Facilities, Equipment, and Conditions. What is the reliability of the equipment? How do facilities and working conditions increase or reduce exposure?
4. Knowledge, Training, and Preparation. Were team members set up for success, and were they prepared with the skills and tools to do the job safely?
5. Brain-Centered Hazards™. How well does the work account for the factors that impact human error and how we operate as humans? Most investigations, or root cause methods, do not adequately or meaningfully address human performance.
Steps in the Event Learning Process
A four-step Event Learning process guides investigators in examining these categories, from information gathering to analysis to identifying corrective actions and ultimately leveraging them for systemic learning across the organization.
Why Event Learning?
This DEKRA solution is a simple but holistic and structured way to use investigations to reduce exposure. Its three critical points of focus—exposure, human performance, and system learning— distinguish it from other systems or methods and ensure meaningful return on investment. Also uncommon, the solution is built to help you succeed, including a pre-workshop assessment, training in a facilitated workshop format, and post-workshop coaching and support.