HOT approach to incident investigation
(Posted on 27/03/19)
Reaping the full benefits of incident investigations is a complex challenge. DNV GL integrated human, organizational and technical dimensions, also known as its “HOT” approach, to help Carnival Corporation & plc develop a more efficient investigation process with outcomes that have greater impact.
DNV GL’s experience from a range of hazardous industries suggests that while most companies are relatively confident about their incident notification and lesson-sharing systems, they often struggle with the critical step in between: the effectiveness of their investigation process.
The maritime industry takes a predominantly reactive approach to high-frequency safety events and human error – action is typically taken after the damage has occurred, rather than proactively. The industry is still learning to understand that reducing occupational accidents has little or no effect on the number of major accidents with more complex causes and more severe consequences. Limiting the focus of attention to the symptoms of malfunctioning systems, or blaming someone who made a mistake, has little effect on the more underlying causes of an accident.
What is needed is a standardized, systematic and traceable investigation methodology that allows companies to identify the root causes of incidents and derive the necessary cultural changes. The incident investigation process should be embedded in a safety management system that unearths underlying causes, explaining both how and why processes in the safety management system succeed or fail. When this is clear, systemic measures for improvement can be identified.
Because of its sheer size and global reach, Carnival Corporation & plc (Carnival), the world’s largest leisure travel company, plays an important role in setting safety standards for the industry. This includes learning from near misses, incidents and accidents to prevent reoccurrence. When performing incident investigations, Carnival was facing the same challenges many in the maritime industry struggle with.
Richard Brilliant, Chief Audit Officer heading Carnival’s Risk Advisory & Assurance Services (RAAS), explains: “We understood that investigations are a powerful tool for learning and improving. Taking a critical look at our processes, we realized there were opportunities to reduce the amount of time it took to perform investigations, to make sure the content and format of reports were appropriate, and that we had a five-star organizational and process model that supported investigator competency and investigation quality.”
AXSMarine, a pioneer and market leader in the provision of advanced solutions for shipping professionals... Read more
The Baltic Exchange has launched a new assessment to track the cost of operating vessels. Initially... Read more
The West of England, a leading mutual marine insurer, has celebrated the 50th Anniversary of its Greek... Read more
Fleet Management Ltd, one of the world's largest independent third-party ship management companies,... Read more
Rotterdam based ship management company Misuga Kaiun Holland B.V. has chosen Marlink to provision cost... Read more
Clipper Bulk, in close collaboration with a financial partner, has acquired three Handysize dry cargo... Read more
A vision of the Ship Manager of the Future and the way ship management companies will interact with... Read more
Arun Sharma, Executive Chairman of the Indian Register of Shipping (IRClass), has been formally introduced... Read more
Leading Classification Society ClassNK has established a cross-sectional cyber security project team... Read more
Fednav Limited has taken delivery of the Federal Montreal, its newest Great Lakes-suitable handysize... Read more