Assess severity & risk context
Severity
Is there potential for a serious incident and what was the specific high risk task context?
Determine what kind of critical risks may have been present while work was performed.
Assess the potential severity of the event to determine whether a serious outcome was probable before a comprehensive analysis is merited.
Determine ineffective controls
Controls
Which critical controls would have stopped an incident from happening?
Identify the key controls that, if fully in place, could have lowered the chances of the incident happening. Check if these controls were fully available and practical for the worker to use. Then, evaluate how effective these controls would have been in preventing the incident.
Antecedents
Which human, operational, and organisational system factors helped to set the scene for the incident?
Analyse the human factors that contribute to absent or ineffective controls. These include unintended or intended work arounds.
Further analysis is then undertaken on whether operational or organisational influences have set the scene for relevant controls to be poorly implemented or not implemented at all.
Make sense of findings & prioritise
Learning
Which factors should be prioritised to resolve the issue?
Review the many causes of the incident to make sure the most urgent issues related to immediate task risks are addressed first. Identify the broader factors that could continue to cause risks if they are not fixed.
Develop actions to strengthen controls
Exposure
Which actions will have the greatest impact on exposure and reduce the potential for a repeat event?
Create actions to address any weakening of controls at the human, operational, and organisational levels.
Wherever possible, redesign controls to make them easier to use and more resistant to human error.