Reducing High Impact Events by Implementing a Deep Dive Process Early in the Event Closure Lifecycle

摘要

The Event Closure Lifecycle did not originally leverage the subject matter expertise of the Error Prevention Point of Contact until later in the process. Assigning a preliminary Impact Index score provides the opportunity to implement a Deep Dive Process. Defining an Impact Index threshold is important when implementing a Deep Dive Process. Events with an Impact Index Score above the threshold trigger the Deep Dive Process. The Impact Index threshold can be reduced periodically to increase Deep Dive Process oversight requirements. The Deep Dive Process augments the Event Closure Lifecycle, leveraging the subject matter expertise of the Error Prevention Point of Contact earlier in the Event Closure Lifecycle. The Deep Dive Process resulted in an increased level of depth and improved results for the causal analysis and corrective action determination / implementation processes. The increased level of depth and improved results ultimately led to a reduction in system risk over time that was obtained by reducing the number of Events with Impact Index over the threshold. The overall level of safety within the enterprise was increased by leveraging the subject matter expertise of the Error Prevention Point of Contact early in the Event Closure Lifecycle.