An investigation report is written for accuracy. Getting it right — establishing the timeline, tracing the causation chain, confirming findings […]
Some incident investigations find a broken procedure. Others find a missing barrier. A smaller but significant category finds something harder
A Bowtie diagram at a Malaysian major hazard facility can pass its annual audit three years running — barriers listed,
Ask an HSE team how many reports a serious incident generates, and the honest answer at most Malaysian workplaces is
Look at a sample of incident investigation reports from Malaysian workplaces and a pattern emerges quickly: most of them have
Ask most HSE Managers what protects their company from liability after an incident, and the answer usually involves a document:
Four separate cases, four separate facilities, and one recurring pattern: the same investigation process, applied to four different situations, produced
Most discussion of incident investigation focuses, understandably, on what goes wrong when a finding doesn’t reach far enough. It’s worth
Bowtie methodology’s independence test is usually applied to equipment: does one barrier share a component, a power source, or a
A HIRARC that passes every audit is not the same thing as a HIRARC that accurately describes the hazards on