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Incident Investigation: A Culture Change Tool?

机译:事件调查:文化改变工具?

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Objective: Incident investigation is one of the most fundamental safety and health tools. It is generally present even in the most stagnant of organizational safety cultures. Trying to change the safety culture of an organization can be a daunting challenge to even the most seasoned of safety and health professionals. Moving culture in the right direction requires either vision or pain. What if there was a tool that could capitalize on both? The OGP published the "Guide to Selecting Appropriate Tools to Improve HSE Culture" in 2010. While they took the approach of picking tools that fit the existing safety culture, whatever it happened to be, this approach looks at what incident investigation tools might actually move the culture forward based on either a vision or pain - and what better way to capitalize on organizational pain than after an incident? Investigation tools then become the proverbial "camel's nose under the tent" to push the culture forward. Methods & Procedures: The steps of the HSE Culture Ladder, along with their respective definitions, in the IOGP Report 435, A Guide to Selecting Appropriate Tools to Improve HSE Culture were reviewed. Since the descriptions of investigation tools and processes in the report are minimal, a review was performed of best practices in incident reporting, investigation and root cause. Each of these practices was reviewed in light of the general HSE Culture Ladder step descriptions and these tools then placed in one of the levels. For each level of the HSE Culture Ladder, detailed descriptions of how the various incident reporting, investigation, and root cause analysis tools would be used at the respective levels were written. Results & Conclusions: The result was a tool with which an existing incident reporting, investigation and root cause analysis program can be reviewed to determine what level on the HSE Culture ladder the program falls. This provides a very good indicator of where the overall company safety and health culture would likely fall, since so many of the programs found in incident reporting, investigation and root cause analysis touch and integrate with so many other programs that significantly affect safety and health culture. The tool also provided a road-map of progressive implementation steps a company can use to move forward their incident reporting, investigation and root cause analysis programs.
机译:目的:事故调查是最基本的安全和健康工具之一。即使在组织安全文化中最具停滞的情况下通常存在。试图改变组织的安全文化可能是令人生畏的挑战,甚至是最调味的安全和健康专业人士。在正确的方向上移动文化需要视力或疼痛。如果有一个可以利用两者的工具怎么办? OGP在2010年发布了“选择适当的工具来改善HSE文化的指南”。虽然他们采取了适合现有安全文化的采摘工具的方法,但无论发生这种方法,这种方法都会看看事件调查工具可能实际移动基于视力或痛苦的文化向前 - 以及如何利用组织疼痛的更好的方法,而不是事件发生?调查工具随后成为众所周知的“骆驼在帐篷下的鼻子”推动文化前进。方法和程序:HSE文化阶梯的步骤以及各自的定义,在IOGP报告435中,综述了选择适当工具以改善HSE文化的指南。由于报告中调查工具和流程的描述是最小的,因此对事故报告,调查和根本原因进行了最佳实践进行了审查。根据一般的HSE培养阶梯描述,这些实践中的每一个都被审查,然后将这些工具放在其中一个级别中。对于HSE文化阶梯的每个级别,详细描述了如何在各个层面使用各种事件报告,调查和根本原因分析工具的描述。结果与结论:结果是可以审查现有事件报告,调查和根本原因分析方案的工具,以确定计划跌倒的HSE文化阶梯上的级别。这提供了一个非常好的指标,总体公司的安全和健康文化可能落下,因为事件报告中的许多节目,调查和根本原因分析触摸并与许多显着影响安全性和健康文化的其他计划。该工具还提供了一条渐进实施的道路映射,公司可以使用该公司可以用于前进他们的事件报告,调查和根本原因分析计划。

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