2022 FDSOA Health and Safety Conference

Reviews are conducted in three parts.  Discovery, Analysis, and Interpretation.  

This session will use actual incidents to demonstrate how to conduct the Review process.  The Review process goal is to learn from incidents that had unintended consequences, or resulted in a close call.  Reviews seek to understand the deep context of the incident and apply that to the learning process.  Reviews ask peers to conduct the analysis which is a facilitated process that must be learned.    

Commonly, investigations are conducted with the general sense that the investigative findings will result in some degree of blame or "holding someone accountable".  We found this approach to be less condusive to building practices for a high reliability organization.  So we set out over several years to develop a more thorough review process.  

Reviews support learning through understanding the context surrounding the incident.  It is a more contemporary approach for post incident learning.  

Attendees will be equiped to conduct a three-part post incident review of unintended consequential events and close calls.