The Best Incident Investigation Performance Indicator

What is the Best Incident Investigation Performance Indicator?

If an incident investigation’s corrective actions are effective, they will prevent (or significantly reduce the likelihood or consequences of) a repeat incident.

If we want to monitor the effectiveness of our incident investigation, root cause analysis, and corrective action processes, perhaps the best performance indicator is monitoring the rate of repeat incidents.

If an incident (or even a Causal Factor) is a repeat, it indicates a problem with the previous investigations. For example:

• Was the root cause analysis inadequate?
• Were the corrective actions ineffective?
• Why didn’t management or peer review catch the problem with the previous investigation?
• Did the corrective actions get implemented effectively?

Of course, the question that is tough to answer is … What is a repeat incident (or Causal Factor)?

What is a Repeat Incident?

Judging repeat incidents takes some soul-searching. The real question is:

Should the previous incident investigation
have prevented the current incident?

Here are two examples:

• Should the investigation and corrective actions for the Challenger Space Shuttle accident have prevented the Columbia Space Shuttle accident?
• Should the BP Texas City fire and explosion accident investigation have prevented the BP Deepwater Horizon accident?

You be the judge.

What is Your Repeat Incident Rate?

What is the rate of repeat incidents or Causal Factors at your facility? Do you have 80% repeats? 10%? 0.1%? Do you even track repeat incidents or Causal Factors?

Each repeat incident provides a learning opportunity to improve your incident investigation, root cause analysis, corrective action, and incident review processes. Are you identifying these opportunities and improving your investigations and corrective actions?

Learn to Improve Your Incident Investigations

There are two tracks at the upcoming 2024 Global TapRooT® Summit on April 29 – May 3, being held at the Horseshoe Bay Resort near Austin, Texas, that can help you improve your investigations and improvement processes.

TapRooT® Summit – Improving Investigations & RCA Best Practice Track

This track was built to help investigators acquire skills to take their investigations to the next level. In this track, attendees will review real-world examples to fine-tune their SnapCharT® diagrams and learn the newest causal factor techniques.

Attendees will also learn investigation improvement techniques by participating in best-practice roundtable discussions with other TapRooT® users and experts from across industries. This type of networking across industries and expertise can lead investigators to unique solutions to take back and implement at their company.

The sessions in this track include:

• ICBM Accident Part 1: Advanced SnapCharT® Diagram Techniques
• ICBM Accident Part 2: Advanced Causal Factor Techniques
• Corrective Action Workshop
• Unique Ways to Use TapRooT® (Roundtable Discussion)
• Partnering with Law in your Investigations
• Capturing Culture Differences Using TapRooT® RCA
• Implementing Your Best Ideas
• Investigative Interviewing: The Psychology of Nonverbal Communication
• Managing Your Improvement Backlog (Resource Schedule)

TapRooT® Summit – Better Improvement Programs & CAPA Best Practices Track

The Better Improvement Programs and CAPA Track is for people who want to improve their improvement efforts and CAPA programs. Do you want to improve your incident investigation program and become more proactive? Do your CAPA efforts need improvement to prevent regulatory issues? You need to learn from industry leaders and their success stories.

This track contains valuable information/best practices, including how to build a successful improvement program and learning from success. See the track sessions below.

• Workshop: How Do You Build a Successful Improvement Program?
• Destroying Silos Using Cross-Functional Teams to Identify the Problem
• Using Trending to Manage Improvement
• Air Canada Maintenance: Implementation Success Story Update
• Learning From Success to Improve Future Performance Using TapRooT® RCA
• Implementing Your Best Ideas
• Lean & TapRooT® Eliminating Waste & Unnecessary Tasks
• Managing Your Improvement Backlog (Resource Schedule)

Register for the Global TapRooT® Summit!

The 2024 Global TapRooT® Summit will be held at the Horseshoe Bay Resort near Austin, Texas, from April 29 to May 3.

The special pre-Summit Courses are on April 29-30. See all 11 optional courses HERE.

The Summit (on May 1-3) has excellent Keynote Speakers that will share valuable information and inspire you to go back to work and implement the best practices you have learned.

If you haven’t registered already, CLICK HERE to register NOW!

To download the Summit brochure, CLICK HERE.

If you have an improvement team, consider bringing everyone. Here are the multiple attendee discounts…