How we do it
The Prosolve process of investigating Organisational incidents and accidents is as follows:
Stage 1: Determining the facts. An engineering analysis is completed, followed by a series of comprehensive interviews and documentation reviews. At this stage, a preliminary draft report highlighting significant questions or issues of interest, can be written for management. However this report is very preliminary.
Stage 2: A detailed preliminary draft report collating and summarising the facts is written and distributed to those involved in the incident and who contributed to the fact gathering process. This is the draft review process and is necessary to confirm factual correctness. An analysis section can be written at this stage, but for some incidents, this is better left to the workshop which is the next stage.
Stage 3: A workshop is convened to discuss the factual findings of the report. It is necessary that all stakeholders attend and this can last up to a day. The workshop begins with a presentation portraying two major calamitous case studies utilising the Swiss cheese and failure drift causal analogies. These case studies provide a de-biasing defence against the hindsight bias and show that even the best of us make mistakes. Following this, the report written above – still in draft status, is worked through in discussion, with additional comments and contributions by all attending. The workshop concludes with a summary of discussion findings.
Stage 4: The preliminary draft report is modified to include information discussed and agreed in the workshop above. It may support recommendations which are able to be issued to other stakeholders or parties. A final report can now be issued.
Stage 5: Issue final report.