WRMC 2022 Pre-conference
Building a Risk Management Information System (RMIS): A Deep Dive into analyzing Contributing Factors and Mitigating Factors through Incident Database Tracking and Business Analytics Tools
Workshop Description
Incident and close call data collection is a fundamental part of any program’s overall risk management strategy. Reviewing individual incident report forms is important, but that won’t give you a holistic picture of your organization’s risk or show you trends across the organization. In order to truly understand and manage risk you need to track incidents and close calls in a database and utilize new advances in data analytics to uncover trends across your data. A Risk Management Information System combines structured data collection with Business Intelligence (BI) tools to provide you with consistent data for all incidents.
We’ll use the Risk Assessment & Safety Management (RASM) model as an entry point to analyze contributing factors in an incident and develop the response plans for mitigation strategies to reduce risk. From there we will explore the Systems Thinking approach of Jens Rasmussen for the range of contributing factors that can occur both inside and outside of an organization. We’ll use case studies to examine these concepts in detail, both a well-known sample accident, and participants will be able to analyze their own accidents. Participants will learn how to use a causal taxonomy for relating contributing factors and build an Accimap, a graphical representation of the interactions between contributing factors. The next stage of the workshop will be exploring the basic concepts represented in Safety II – that is how positive operations and practices prevent accidents from occurring. Rather than only looking at “what we do after the bad thing happens and how we keep it from happening again”, participants will also learn to focus on “what’s working now.” In this section participants will assess positive safety/mitigation factors that prevented an accident from occurring and build a Preventimap, a graphical representation of the interactions between risk prevention factors. Participants will get hands-on practice using online business analytics to review and assess trends with sample data from the IncidentAnalytix system.
Workshop Instructions
The goal of this workshop is to give you a grounding on some of the latest risk management frameworks and hands-on experience with practical tools that you can use to collect and analyze incident and close call data. The best way to do that is to go beyond theory and explore real world situations so as a case study to help our explorations we will use a well-documented outdoor education accident from New Zealand, the Mangatepopo Gorge tragedy from April 2008. Please read the attached article that presents an overview of the event. You’ll be working with this case study in small groups to do an incident analysis using various frameworks.
In order to help you connect the workshop content to your own work, please think of an incident or close call either from your program or your personal experience that you are comfortable reviewing before the workshop. This won’t be shared with anyone else, but I have found that in taking theory to practice, being able to analyze your own experience through a new lens is a powerful learning tool. Having an event in the back of your mind throughout the workshop may create some ah-hah moments.
If you do not have an incident, then pick a historical event and gather some brief data about it before the workshop. Two good examples are the 1986 Challenger Shuttle Disaster (https://en.wikipedia.org/wiki/Space_Shuttle_Challenger_disaster), or the 1996 Everest Expedition (https://en.wikipedia.org/wiki/1996_Mount_Everest_disaster) chronicled in Jon Krakauer’s book Into Thin Air: Death on Everest. I’ve enclosed a sample incident form in case you want to jot down some basic information about the event.
The overall workshop will be 4 hours. We’ll take two 10-15 minute breaks during the afternoon. I encourage everyone to bring a laptop since we will be working through some samples on either Microsoft Excel or Google Sheets and you’ll be exploring some of the business intelligence tools with live data on the web.
Pre-Conference Materials
Please review these materials before the conference.
- Tenth Anniversary of the Mangatepopo Tragedy, – Lessons Learned.pdf
- Incident Event Summary Form.docx
Conference Handouts
- Conference PowerPoint (PDF with speaker notes)
- SystemsThinking – A New Direction in Healthcare Incident Investigation (YouTube)
- Nassar AcciMap (PDF)
- Generic Taxonomy – Salmon et al (Excel)
- Sample Taxonomy MindMap (PDF)
- Demo Mangatepopo Cross-functional Flowchart for Visio (Excel)
- Demo Visio AcciMap generated from Excel Cross-Functional Flowchart (PDF)
- Hierarchical Task Analysis (HTA) of 5-day Led Outdoor Activity – Clare Dallat, Paul Salmon, Natassia Goode (MindMap PDF)
Key Literature
- Sample AcciMap/PreventiMap Template PDF
- Risk Management in a Dynamic Society: A modeling problem – Jens Rasmussen (1997)
- From Safety-I to Safety-II: A White Paper – Hollnagel E; Wears RL; Braithwaite J. (2015)
Other Resources
- 1.5.5 Safety I vs Safety II – https://www.youtube.com/watch?v=WM0LVv9NrhM
- Doing Safety Differently – Sydney Dekker: https://www.youtube.com/watch?v=6gREMV6j2A4
- Safety II & Safety II – Erik Hoffnagel: https://vimeo.com/channels/1366431/89492241
- Perceiving what cannot be seen” ‐ the practical side of Safety ‐ II – Erik Hollnagel: https://vimeo.com/159498494
- A story of Safety II – Jeffrey Braithwaite: https://www.youtube.com/watch?v=gauR843rRNk
- Safety Differently | The Movie: https://www.youtube.com/watch?v=moh4QN4IAPg
- Sidney Dekker — Safety Differently Lecture: https://www.youtube.com/watch?v=oMtLS0FNDZs
- Sidney Dekker — Just Culture short course 1: https://www.youtube.com/watch?v=PVWjgqDANWA
- The New View of Safety with Todd Conklin: https://www.youtube.com/watch?v=IoYUQlWiRgc
- Dr. Todd Conklin speech “Risk Analysis is Fixed in Time – But Hazards Ebb and Flow: https://www.youtube.com/watch?v=X211fU39808
- Guidelines for AcciMap Analysis: https://openresearch-repository.anu.edu.au/bitstream/1885/20987/2/01_Branford_Guidelines_for_ACCIMAP_2009.pdf
- Webinar: An Introduction to “New Safety” (HOP, Safety II, and Safety Differently): https://www.youtube.com/watch?v=zqZVGaFIhyw
- FAA Safety Management Systems (SMS) Fundamentals: Policy: https://www.youtube.com/watch?v=j8N0PZx5YwM
- FAA Safety Management Systems (SMS) Fundamentals: Safety Risk Management Component: https://www.youtube.com/watch?v=b6dwxQ3oEAE
- Mangatepopo canyoning tragedy a decade on: ‘I know they would be loving every minute of life’: https://www.nzherald.co.nz/nz/news/article.cfm?c_id=1&objectid=12032068
- In a Flash TV Movie: https://www.tvnz.co.nz/shows/in-a-flash/episodes/s1-e1
- BBC NASA Challenger Disaster: https://www.youtube.com/watch?v=reM5fTo-6PI
- Challenger Disaster Governmental Report: https://www.govinfo.gov/content/pkg/GPO-CRPT-99hrpt1016/pdf/GPO-CRPT-99hrpt1016.pdf
- A Review of Accident Modelling Approaches for Complex Critical Sociotechnical Systems: https://www.semanticscholar.org/paper/A-Review-of-Accident-Modelling-Approaches-for-Qureshi/c3a597212068c27be45d84dec76e86baabd4cf90