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    ANALYSING THE ROOT CAUSE OF INCIDENTS

    NRI issue ‘Graphical Model’ to simplify and improve investigation tool

    The Noordwijk Risk Initiative (NRI) Foundation was founded in 1998 to encourage sharing of knowledge in the field of risk management.

    In 2000 the 3CA method of incident root cause analysis was developed to help first-line supervisors in the UK Chemical Industry.

    The aim was to design a tool that helped supervisors analyse root causes of incidents. The tool was easy to learn and helped produce insightful and useful findings quickly. The result is still available and is now called 3CA Form A.

    In 2008 NRI published a new version known 3CA Form B designed for safety professionals in mind but still able to be used by others. The process was “made more thorough and less prone to judgmentalism”.

    New graphical model now available

    NRI has now prepared a Graphical Model in partnership with the Health and Safety Executive (HSE) that has been developed after trials involving some 200 users.

    The new format invites users to move back and forth between the various headings and enables the outputs to be more easily used by those not involved in the investigation.

    The Graphical Model is available from June 2010 on the NRI website. It can be used with the Form B manual or the draft Draft Form C Manual.

    Comment

    Assessing the underlying human and organisational causes of incidents is the central to effective prevention – see Reducing error and influencing behaviour HSG48.

    Investigating accidents and incidents – HSG245 published by HSE is designed to enable organisations to learn lessons through systematic investigation. This workbook presents a four-step approach:  information gathering; analysis; identifying risk control measures and implementing solutions.

    The NRI system provides one way of uncovering the root cause of incidents.

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