"Stop investigating events": Combining in-depth and HOF driven analysis of work, as performed in the reality of day-to-day operations
Authors: Carpinelli Fabrizio , Accou Bart 
Published: June 2024

In high-risk industries, a lot of time and effort is invested in reporting and investigating accidents, incidents, and other types of events, to finally result – very often – in a collection of little useful information vis-à-vis explicit safety- and/or risk management. This leaves the loop of continuous improvement of the organisation of safety open, and similar events to happen again. With such an approach, the future of the safety management system (SMS) seems compromised.There are several reasons for this. The scope of the investigations is often limited to the immediate causes and operational decision-making close to the adverse occurrence, insufficiently addressing essential elements of safety management. The investment in event investigation is often too dependent of the consequences (damages), with its corollary of attributing responsibilities and judging errors, instead of analysing deficient barriers “before or after” the variability of performance. Reporting is not encouraged enough, and what is considered relevant to report is not taken from an operators’ view, the difficulties they experience in day-to-day activities, or the residual risks managed. More education, training and methods are needed to better understand the real practice of a SMS, particularly when it is about integrating the influences of/on human and organisational factors and creating an environment that fosters the development of a positive safety culture. The key question is: how are these events made possible in our current SMS practice and how to improve it? Therefore, instead of limiting the analysis of these occurrences to understanding what happened, and investigating only the event, investigators should explore the composite elements of the SMS that is -often by law or recognised standards- expected to control the risks related to these operational activities. They can do that by linking the findings close to operations that explain the occurrence (being the elements investigators are first confronted with) with the relevant set of control and implementation processes that influenced the chain of events and form part of the SMS. When doing this in a supportive and structured way, it guides investigators through the different operational, tactical, and strategical levels that together form a socio-technical system. The proposed method also supports to go beyond one SMS, taking all stakeholders’ contributions into account when needed, even at the level of regulatory authorities.Building on the SAfety FRactal ANalysis (SAFRAN) method (Accou and Carpinelli, 2022), and describing our didactical attempts to disseminate it, this paper explores how to combine in-depth and HOF driven analysis of work, as performed in the reality of day-to-day operations, with an understanding of the organisational settings in which this work takes place, taking also into account the SMS as reference. This, in turn, is expected to result in recommendations that, rather than focusing on technical and operational aspects, address the capability of responsible organisations to manage safety critical variability, leading them towards closing the loop of continuous improvement and, at the end, towards a more sustainable, safe and resilient performance.