事故调查和根源探究.ppt

There are several pitfalls that should be avoided when seeking the root or system cause(s) of an incident: Personal factors alone do not cause incidents. If a person’s attitude or behaviour appears to cause an incident, some failure in the safety system made it possible for the attitude or behaviour to override the system. The objective is not to find fault or place blame. The system causes are being sought so that faults in the safety systems can be corrected. Do not blame specific individuals as the only root cause. Problems do not come so much from the way people work but from the way they are managed. If people are not working safely, the systems are failing to control the safe actions of workers. It is the supervisor’s responsibility to make sure employees work safely. The priorities at the incident scene must be as follows; Your Safety – Do not add to the problem Others Safety – Don’t make matters worse Casualties – Treatment of others can now be organised Evidence – Once the above issues are dealt with, we can turn our attention to evidence. Now that we have evidence we must now process it. At the heart of any meaningful investigation is the ability to conduct a fair, ethical and detailed Investigative Interview. The skills required are many but primarily the good interviewer will listen actively and ask carefully selected questions designed to establish specific information. Question Types Open = Invites the interviewee to give a detailed wide-ranging answer. Open questions are beneficial in establishing information and setting an agenda. Closed = Invites a one-word reply. Useful when summarising and/or confirming information. 5WH Who What Why – (Ensure this question does not make the interviewee defensive!!) When Where How As there are good quality questions there are also poor quality questions. Among the most commonly used poor quality questions are; Leading – “How fast/slow was the truck travelling?” Better to ask, “How would you d