Do your audits and investigations force you into uncomfortable territory? Or do they safely maintain your existing risk blindspots?
It seems many processes still focus on what happened, and who was involved. Fewer push into harder questions, like engineering flaws, missed warnings, production pressure, or known issues that sat unresolved.
Emeritus Professor Michael Quinlan developed a High Potential Incident summary form based on his Ten Pathways Model (FYI check out his book ‘Ten Pathways to Death and Disaster).
This simple tool deliberately pulls attention toward areas that are overlooked, like:
a. Did a failure in engineering, design or maintenance contribute?
b. Was the work adequately risk assessed in the first place?
c. Had audits already been done and did they actually identify the problem?
d. Did cost-cutting, time pressure, or resourcing constraints play a role?
e. Were concerns raised beforehand, and what happened to them?
Full form available via the description: https://youtu.be/_V_xJ5qDxnE?si=6e1ZcMDy4p3lh0cT
This isn’t really a causal analysis tool, so much as a sense and assumption check.
SafetyInsights.org 