Reaping the full benefits of incident investigations is a complex challenge. DNV GL integrated human, organizational and technical dimensions, also known as its “HOT” approach, to help Carnival Corporation & plc develop a more efficient investigation process with outcomes that have greater impact.
DNV GL’s experience from a range of hazardous industries suggests that while most companies are relatively confident about their incident notification and lesson-sharing systems, they often struggle with the critical step in between: the effectiveness of their investigation process.
The maritime industry takes a predominantly reactive approach to high-frequency safety events and human error – action is typically taken after the damage has occurred, rather than proactively. The industry is still learning to understand that reducing occupational accidents has little or no effect on the number of major accidents with more complex causes and more severe consequences. Limiting the focus of attention to the symptoms of malfunctioning systems, or blaming someone who made a mistake, has little effect on the more underlying causes of an accident.
Identifying root causes of incidents
What is needed is a standardized, systematic and traceable investigation methodology that allows companies to identify the root causes of incidents and derive the necessary cultural changes. The incident investigation process should be embedded in a safety management system that unearths underlying causes, explaining both how and why processes in the safety management system succeed or fail. When this is clear, systemic measures for improvement can be identified.
Because of its sheer size and global reach, Carnival Corporation & plc (Carnival), the world’s largest leisure travel company, plays an important role in setting safety standards for the industry. This includes learning from near misses, incidents and accidents to prevent reoccurrence. When performing incident investigations, Carnival was facing the same challenges many in the maritime industry struggle with.
Richard Brilliant, Chief Audit Officer heading Carnival’s Risk Advisory & Assurance Services (RAAS), explains: “We understood that investigations are a powerful tool for learning and improving. Taking a critical look at our processes, we realized there were opportunities to reduce the amount of time it took to perform investigations, to make sure the content and format of reports were appropriate, and that we had a five-star organizational and process model that supported investigator competency and investigation quality.”
HOT dimensions of safety management
In pursuing its continuous improvement philosophy, Carnival launched an initiative to assess their incident investigation process against best practice, with an emphasis on identifying the root causes of incidents. Asked to assist Carnival in this process, DNV GL offered its “HOT” approach that highlights the interdependencies between the human (H), organizational (O) and technological (T) dimensions to optimize management performance and foster a mature organizational culture.
In this scheme, the management system assessment (O) is based on DNV GL’s International Sustainability Rating System (ISRS), which represents best practice in safety and sustainability management. It is designed to help customers understand how to manage complex and emerging risks and demonstrate to their stakeholders that their risks are under control. Incident investigation is included in the ISRS “Learning from Events” process.
DNV GL’s approach to safety culture assessment (H) includes a tool for digging into the underlying causes of identified weaknesses in safety performance. It reveals discrepancies between the intended processes of a safety management system and what actually happens on the work floor.
The combination of these two assessments helps organizations chart gaps between their governance on risk (risk management in theory) and the employee perception of risk (risk management in practice).