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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.”