Incident investigation case study

Introduction

Access Free Samples Prepared by our Subject Matter Experts, known for offering the Best Online Assignment Help Services in Australia.

Incident investigation is defined as the focus on the identification of the root causes of any incident and to identify the fall to within that incident. Within the workplace there are many different types of incident taking place and it is the responsibility of the company that the effectively take care of these incident and try to find the root cause. The current study will analyse the incident which took place in August 2016 where in an offsider was attacked and was injured. The current study will outline the accident with help of the different techniques like the fish bone analysis and event and causal chart analysis. In addition to this the detailed analysis of the accident will take place. At the end based on the incident summary, the evaluation of the recommendations made and the level of success of Investigation will be undertaken.

Main Body

Presenting Event and Causal chart along with RCA using fishbone

Event and causal chart

Event and casual factor is a type of chart with assist in depicting the sufficient events and the factors for the occurrence of the accident within a logical sequence. This is particularly necessary to effectively use the chart so that the discussion can be done effectively and appropriately (Tayab and et.al., 2019). The event and casual chart of the current case includes the two causes of the accident that is the direct causes and the contributory causes. This even and casual chat assisted in outlining the direct causes and contributory causes differentially.

RCA with fishbone

RCA that is root cause analysis is a type of problem solving approach which helps in identifying the reasons behind any problem. This fishbone technique helps in arriving at the appropriate solution by bridging the gap between cause and effect of the event (Patel and et.al., 2022). With the help of the current fishbone analysis it is clear that the incident took place in August 2016 and thereof the hole in accident took place where in the person was hit over another vehicle and was grounded.

Summarising the findings based on analyses

With the help of both the analysis it is clear that the accident took place and there were different reasons relating to it. The first and foremost was the direct causes which led to the occurrence of the accident. The direct causes included the fact that the offsider did not follow the return to neutral safety function and as a result of this the vehicle got imbalanced. In addition to this, at time of climbing back the person was not able to get away of the moving vehicle. Thus, as a result of this accident took place and it result in injury of the person (Significant Incident Report No. 249, 2016). In addition to these direct causes there are some contributory causes as well. The first and foremost contributory cause identified was that the control lever of the vehicle was modified and as a result of this the vehicle was allowed to move by themselves that is the vehicle had the capability to move without a person.

Enjoy Additional Savings on WhatsApp order!

Scan the QR code with your mobile to unlock an exclusive offer! use my discount

Thus, as a result of this chances of accident increased and the accident took place. In addition to this another contributory cause of the accident was that he safe operating procedure was not followed while running the vehicle (Waterson, 2021). Hence, as a result of this accident took place and it harmed the person. In addition to this, another contributory cause which led to the accident was that the ladder was removed for maintenance and as a result of this the vehicle got imbalance and the accident took place. Collectively the combination of direct and contributory causes is the major root cause of the happening of the accident. This as a result of this the person was harmed and it affected the efficiency of the person to a great extent.

Based on incident summary

Investigation was able to found all relevant causes

With the evaluation of the accident report it is clear that the investigator was able to find all the relevant causes of the accident. This is particularly because of the reason that with help of the event and casual chart along with RCA chart using fish bone it is clear that all the causes of the accidents have been identified. In addition to this causes are classified in different headings and this made it very clear to understand them situation and the whole accident (Touloumis and et.al., 2022). With the evaluation of the accident it is clear that majorly there are two different causes which resulted in the accident please causes included direct cause and the contributory causes. Both these causes have resulted in occurrence of the accident and as a result of this person are injured

Appropriateness of recommendations

Further with the evaluation of the recommendation it is clear that the investigator has provided correct recommendations. This is particularly necessary because the accident took place due to many different regions. And the different to recommendations were provided which included modifying the plant complaint with safe work procedures. In addition to this another recommendation made wasn't relating to maintenance that is the company must implement effective hazard reporting system for mobile plant as well (Lam and Tai, 2020). This is necessary because it will help in reporting each and every hazardous activity easily. In addition to this another recommendation provided was to implement a mobile plant maintenance system which included periodic inspections. This will definitely help the company in analysing each and every stage and try to improve the working. With help of the periodic inspections the work can be managed easily and as a result of this all the negative aspects can be solved easily. This with help of the evaluation of these recommendations it can be stated that all the recommendations provided are appropriate and helpful in solving the current problem.

Level of success of investigation and difficulties faced by investigator

With the evaluation of the current situation it is clear that the investigation has been successful. This is particularly because of the reason that the investigator was in condition to identify the appropriate causes of the problem (Rivera and et.al., 2019). Thus, as a result of this the investigator was able to successfully investigate the accident. Along with this with the evaluation of the accident it was clear that the proper recommendations were also provided in order to solve the problem. Hence, with this it can be stated that the level of success of Investigation is higher as the investigator was able to solve all the questions easily and effectively. Also with help of the investigation it was clear that the investigation was successful because the investigator was in condition to provide appropriate recommendations for improving the problem. In case the investigator was not in position to provide good recommendations then it might be possible that the investigation is not successful. But in the present case the investigator has provided different kind of recommendation for improving the problem and reducing the occurrence of accident. Thus, it can be stated that the current investigation has been made successful.

Further with the evaluation of the accident it was clear that there were many difficulties with the investigator faced while investigating. The most common problem or the issue faced by the investigator walls going to the place of accident and to evaluate the situation. This was the major issue which the investigator faced. This is particularly because of the reason that at the accident place there were many different aspects to be studied. Thus, it was difficult for the investigator to identify which is the most important aspect for the valuation of the accident. Hence, as a result of this it was the major issue which the investigator faced in order to decide that which aspect is most appropriate for the solution of the case (Shipunov and et.al., 2021). Along with this another major difficulty which the investigator faced was that the process was highly time consuming. The investigation process was time consuming and it in reduction of efforts of investigator in other activities. The investigator had to focus continuously over the investigation only so that the root causes of the accident can be identified. In case the investigator deviates from the process of solving the case then it will be affecting the efficiency of the case.

Conclusion

In the end it can be concluded that investigating the incident is very necessary for the solution. This is particularly necessary because good investigation will help the investigator in identifying the causes of the accident and ways of solving it. The above study outlined the fact that major cause included direct and contributory causes. On the other hand some recommendations were also provided which includes complying with safe work procedures and modifying the plant.

References

Books and Journals

• Lam, C. Y., & Tai, K. (2020). Network topological approach to modeling accident causations and characteristics: Analysis of railway incidents in Japan. Reliability Engineering & System Safety, 193, 106626.
• Patel, D., Bhuptani, C., Lubian, J., Acharya, J., Mukherjee, S., & Lawrie, J. J. (2022). Investigation of alpha particle emission from the 14N+197Au reaction at an incident energy of 250MeV. In Proceedings of the DAE Symp. on Nucl. Phys (Vol. 66, p. 543).
• Rivera, N. R., Kassim, B., Grigorov, P., Wang, H., Armenante, M., Bu, X., ... & Variankaval, N. (2019). Investigation of a flow step clogging incident: a precautionary note on the use of THF in commercial-scale continuous process. Organic Process Research & Development, 23(11), 2556-2561.
• Shipunov, I. S., Nyrkov, A. P., Ryabenkov, M. U., Morozova, E. V., & Goloskokov, K. P. (2021, January). Investigation of computer incidents as an important component in the security of maritime transportation. In 2021 IEEE Conference of Russian Young Researchers in Electrical and Electronic Engineering (ElConRus) (pp. 657-660). IEEE.
• Tayab, M., Valappil, S., Shah, V., Azhibekov, T., Zeinati, M., Al Ameri, M., & Al-Hameli, F. (2019, November). Sequential Failures in Incident Investigation Process Hindering Prevention of Incidents. In Abu Dhabi International Petroleum Exhibition and Conference (p. D011S015R001). SPE.
• Touloumis, K., Michalitsi-Psarrou, A., Georgiadou, A., & Askounis, D. (2022, December). A tool for assisting in the forensic investigation of cyber-security incidents. In 2022 IEEE International Conference on Big Data (Big Data) (pp. 2630-2636). IEEE.
• Waterson, P. (2021). Promoting systemic incident analysis in healthcare—key challenges and ways forwards. International Journal for Quality in Health Care, 33(4), mzab139.

Online

• Significant Incident Report No. 249. 2016. [Online]. Available through: < https://www.dmp.wa.gov.au/Documents/Safety/MSH_SIR_249.pdf>