The TOP-SET Investigation System is simple, straightforward and easy to use. We make no apology for following the KISS principle. If we have to teach a wide variety of individuals, with different skills and abilities, we have to provide a straightforward and easy-to-understand system. What’s more, many who use our system have English as their second language, so jargon and unnecessary complexity must be avoided.
However, some years ago, we read in a ‘comparison’ article that the TOP-SET system is for low and medium-level incidents. We guess this was because the author thought that a simple system equated to simple incidents. This couldn’t be further from the truth. The Kelvin TOP-SET methodology was used to investigate the Deepwater Horizon incident almost a decade ago, and our investigators were working there for almost two years.
We claim our system can be used for any level of incident, but this presents significant issues to consider. One of the most difficult is deciding whether an incident merits investigation and at what level. Our Incident Statement insists that the Consequences and Potential Consequences of any incident are considered right at the outset. Let’s imagine a load fell by mistake, but there were no consequences, i.e. the load and the floor/deck were not damaged, and no one was injured. This would be what some describe a ‘near miss’, although if you think about it, that’s the wrong term. It should be a ‘near hit’!
There is a major conundrum in the investigation of near hits, and it’s this: is it worth investigating incidents where there are no consequences?
Here are the pros and cons, in a nutshell:
FOR:
By investigating every incident, no matter how trivial, you are ‘listening to the whispers, so that you never have to bear the screams’. You are learning from errors, not being threatened by them; you are making full use of the ‘free lessons’ on offer.
AGAINST:
Time is precious and there is much to do. Can you afford the time to investigate these ‘trivial’ or non-occurrences? Perhaps not, but remember these are missed opportunities to uncover flaws in the system and be proactive about safety.
Secondly, if you report all these incidents, on the face of it, your company will appear to be awash with incidents and not a great place to be! You have 30 incidents a month, and your main competitor has only two. Does that make your competitor better than you? Certainly not! Never believe statistics without pausing to consider their origins and the background calculations.
When considering the arguments above, remember the value of the Potential Consequences. No matter how trivial the incident, if the potential for it to escalate to a major incident was high, then it must be investigated. That’s the beauty of the Potential Consequences (PC), which we insist is always included in our Incident Statement. One word of caution, however – your PC must always be a reasonable expectation, not an outrageous hypothesis, as you will lose staff interest and buy-in to the investigation process itself. This is where diverse teams come in, which reduce the potential for outlandish hypotheses and bias, even if just a team of two is available.
So there is a balance to be reached when judging the type and level of incident to investigate, and this of course varies from company to company depending on size, budget, resources and country. But whatever your policy on this, TOP-SET is scalable and can be used for them all, from minor to complex. There is always something to learn from an investigation done well.