Incident Investigation

Accidents and near misses should be investigated, and actions taken, to prevent recurrence, allowing organizational learning and improve operations of the business. The Tripod Beta investigation and analysis methodology is unique with respect to the following aspects:

  • Tripod Beta differentiates clearly between the physical “happenings” (that cannot be influenced by the organization, e.g. an explosion results from a gas cloud meeting a spark) and the man-made barriers (human actions or controls/protective measures) that could have prevented the final damage. If an accident occurs, usually many barriers, that were supposed to be working, had failed.
  • Barriers, being man-made, usually fail as a result of human actions. Therefore we must identify the action or omission that made the barrier fail. We call these Immediate Causes.
  • Tripod Beta acknowledges that making errors is only too human and that people usually try to do a good job. Therefore Tripod Beta is not interested in blame or guilt. Certain circumstances (called Preconditions) can increase the probability of occurrence of the Immediate Causes, e.g. insufficient understanding of the situation or adverse ergonomic conditions. We must understand which Preconditions were valid for each identified Immediate Cause.
  • Preconditions exist usually because failures in the organization’s management system. Understanding of these Underlying Causes, that indirectly cause accidents, is the ultimate goal of a Tripod Beta investigation.

Organizational learning only occurs if both problems at the operational level (failed barriers) areĀ  fixed AND Underlying Causes are addressed. Leaving Underlying Causes unsolved will simply result in accidents happening at different places.