Optimizing Fact-Finding In Incident Investigation And Analysis Using Tripod TRACK
Authors: Verhoeve K.N.R. , Wolsak T.D. , Groeneweg J. , Lancioni G.E. , Metaal N. 
Published: December 2007

Incident investigation and analysis is an essential part in identification of risks and managing the business process. The quality of the investigation and analysis determines on what level remedial actions can take place. The better the investigation and analysis, the more one finds the systemic causes of incidents. By identifying and remedying these systemic causes, entire classes of incidents can be prevented.

Based on the Tripod theory, Tripod Beta has been developed as an instrument to analyse incidents. Tripod Beta is seen as a state-of-the-art method to analyse incidents. The method itself however is not explicitly designed for fact-finding, although the Tripod Framework does give a clear direction and supports finding facts.

This paper describes a new tool in the Tripod family: TRACK. TRACK facilitates the process of fact-finding and enables the investigator to get away from the "what happened" to the "what made it happen". Results show that using TRACK increases the consistency and objectivity of the investigation, and forces the investigator to dig deeper than with any other tool available.

Introduction

Since the publication of Human Error in 19901 a consistent trend in the interest in the contribution of human error to industrial accidents can be noticed. The common factor in this trend is the theory that prevention of human error is most effectively gained by controlling the working environment instead of focusing at the individual who ‘failed’.2,3 Safety does not, as many experts believe, depend on the number of sprinklers and hydrants installed, but a high proportion of accidents and catastrophes are the obvious result of management error.4 According to Rasmussen5 accidents are the result of lack of control: ‘A closer look at major accidents indicates that the observed coincidence of multiple errors cannot be explained by a stochastic coincidence of independent events. Accidents are more likely caused by a systematic migration toward accidents by an organization operating in an aggressive, competitive environment. [..] Safety is a control problem.’

To prevent human error a range of techniques are available, some more effective than others. Initiatives like Unsafe Act Auditing, Qualitative Risk Assessment and Technical Safety Auditing are in many companies applied to increase safety. These techniques may be necessary but are not yet sufficient to further decrease the number of accidents.

Essential in trying to improve the safety state of individuals is to acquire insight into the situations that lead to accidents and how those specific situations can be avoided. These factors are not only present at the work floor but also at other supervisory and managerial levels. The most successful ones focus on the managerial responsibility in identification and elimination of adverse conditions at the workplace. Due to the complexity of dynamic organizations, management cannot develop fail-safe long-term solutions. They should therefore not focus on the complete elimination of human error and the corresponding dynamics of human behaviour by enforcing strict compliance with procedures but on the soundness of their organization. They have to control the processes they initiate to remedy deficiencies in the structure of the organization.