Phone: + 31 85 006 4343
Incident Investigation & Analysis
Whenever you experience an accident or near miss, you want a thorough investigation to begin quickly. Evidence must be secured and reviewed, and witnesses must be interviewed. You want to establish the sequence of events, analyse the findings and identify the immediate and underlying causes as soon as possible. Your professional organisation wants to have a thorough and valid investigation, an expert analysis and meaningful and achievable recommendations. Because you and your organisation want to learn and improve.
However, many organisations lack the expertise or the resources to carry out such an investigation, or they want the investigation to be led by an independent expert.
We can help you. Our network consists of independent incident investigators, with each at least ten years of experience. We are familiar with a variety of investigation and analysis techniques, ranging from barrier-based applications such as (B)SCAT, generic Root Cause Analysis, TOPSET, TapRooT, Sologic or highly sophisticated analytical approaches such as FRAM. Often we apply the Tripod Beta approach and all our investigators are Gold accredited by the Tripod Foundation.
You can reach us 24/7 by phone: +31 85 006 4343. We will commit as soon as possible (generally within 4 hours) and, when circumstances are demanding, we aim to be on our way to you within 24 hours.
The incident investigation process
Immediately after your initial call we will ask an available investigator with the right credentials to contact you for a further discussion about your request. He/she will contact you on details and mail you a proposal that you should confirm by e-mail (generally we do not need to wait for a formal purchase order to come into action, since our assistance is often summoned and delivered outside the regular office hours). After receipt of confirmation, the investigator will travel to your site as agreed. It is helpful if you mail him/her pertinent incident details. The investigator will also submit a draft Terms of Reference that should be agreed on early in the investigation phase.
The investigation (site visit, interviews, document and other evidence review) is normally carried out by a team of individuals of the organisation and our investigator. None of the team members should in any way be related to the incident or its potential causes.
The organisation of the investigation, and its deliverables, are agreed with you and stipulated in the Terms of Reference.
Our organisation seeks a high-level performance as well as premium quality of our services. Therefore, each investigation will be peer-reviewed by a colleague and co-member of the Flying Squad.
The Tripod Beta incident investigation approach
Tripod Beta aims to identify the underlying, or organisational, causes that led to the incident. Sustainable improvement only occurs if we address these underlying causes at an appropriate level in the organisation. Though this method seems intricate, it delivers great and substantial results in the hands of our experts.
The Tripod Beta investigation focuses on identifying failed or missing barriers that may have stopped the sequence of events leading to the incident (the 'Swiss Cheese' model). Barriers may comprise of a hardware function, but also of expected human behaviour. To understand the causality of barrier failure, we must identify the Immediate Cause of that failure, which is often a human act. With the benefit of hindsight, we may call that an 'error'. However, experience shows that most people involved in these 'errors' are actually trying to do a good job. Therefore, we must understand what Preconditions can explain the person's behaviour. Usually, these Preconditions are linked to the person's physical, psychological or organisational environment. The organisation creates adverse Preconditions or allows them to continue. These organisational causes are called the Underlying Causes of an incident.