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Hazardex 2017 Conference: What does good look like - Knowledge and competence in high hazard industries

Author : John Wilkinson (ex-Keil Centre & HSE) & Simon Monnington (BP)

03 November 2016

Building on an earlier joint paper by the authors and using the ongoing case study from it, a practical view of investigation as a process and an activity will be provided.  Investigation can be a very challenging activity for many people, whether they are leading or just occasional team members.  The actual impact (recommendations and implementation) can be disappointing after all that effort, too.

Opportunity can be limited either by availability of incidents or by the time and resource made available to investigate.  This makes gaining experience and expertise a challenge.  Investigation methods vary widely too and are often adopted for perceived (but then not fully realised) benefits e.g. better and more detailed root cause identification which in practice is made difficult by multiple drop-down menus and poorly-explained choices, or alleged improved validity and reliability coupled with poor usability. 

Training is often more method- and software-focused and not well consolidated by structured on-the-job training or other practical support.  Human and organisational factors (HOF) are often not included effectively in training and are also very variably addressed in the methods themselves.  Even the best methods are in the end very reliant on the investigators’ own HOF understanding and experience – so claims of HOF integration (and few methods offer this) are often unrealised in practice.

Organisations may try to investigate lower level incidents and near-misses but there may be barriers e.g. their internal incident classification system may only allow a site to deploy limited resource and capability to investigate. The resulting outcomes can then lack depth and rigour, and produce more and longer procedures, re-training etc. and a corresponding reluctance to improve design or other measures higher up the hierarchy of control.  Investigators can only find what they look for and that they have the time, training, support and ‘permission’ to look for.

Investigation depth can also be affected by the contributions from others in the system.  Potential recommendations / actions may be challenged or played down during review and discussions. Lead investigators may feel under pressure not to push findings especially if a senior manager does not really understand the issues concerned (often disguised as ‘these recommendations are not SMART enough, too fuzzy’ etc.) or they reflect poorly on leadership.

This paper offers the views of two very experienced ex-regulatory investigators rooted in a largely non-methodological approach.  They build on an ongoing project which changed BP’s methods and approach significantly, and this is illustrated by an ongoing case study. 

Experience from a wide range of industries and other regulators is also offered with a view to providing pragmatic advice and guidance to industry investigators. Learnings and experience for investigators are offered on investigation method selection, training and practice.  Some of the pitfalls of the more theory-driven methods are discussed.  Wider experience on improving organisational learning from incidents and more widely are also offered together with discussion of the crucial role of a good walk- and talk-through of the task or activity concerned both as a contributor to the incident and in the ensuing improvement process. 


About the Speakers

John Wilkinson is currently an Independent Human Factors Consultant, Writer and Researcher; also an Associate at The Keil Centre, Edinburgh and several other companies. He had five years' consultancy experience with The Keil Centre till 2016. Prior to that, as Principal Human Factors Specialist Inspector and Human Factors Team Leader, he played a key role in setting up and developing Human and Organisational Factors (HOF) for the UK Health and Safety Executive from 1999-2011.

He was lead HSE human factors investigator at Buncefield, and subject matter expert reviewer for the US Chemical Safety Board's Texas City and Macondo reports.

Simon Monnington is Human Factors Advisor, Downstream Safety and Operational Risk, at BP. He is a Chartered Ergonomics and Human Factors Specialist with a track record in incident investigation, safety optimisation and human factors in hazardous industries. Before this appointment a year ago, as Investigations Subject Matter Expert, he was Lead Investigator for Downstream businesses at BP.

Prior to this, Monnington was Specialist Inspector of Health and Safety (Human Factors and Ergonomics) at the Health and Safety Executive and Ergonomics and Human Factors Scientist at the Health and Safety Laboratory.


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