Investigations
Reflekt has extensive experience with incident investigations and root cause analysis. Reflekt has developed methodology to determine why incidents occur and what can be done to prevent them. The methodology includes an assessment of the causes of incidents in relation to the typical causes of Major Accidents.
Reflekt’s basic premise for any investigation is that the people involved believed what they were doing was the right thing in the circumstances they were in and that they had no intention of causing an accident or incident. We need then to understand why they believed this in order to find out how to prevent recurrence.
Reflekt is an advocate of learning from non-accidents. Non-accidents are events that had a satisfactory outcome however may have had steps that nearly went wrong or were saved from going wrong by unplanned interventions or even by luck. How close were you to an accident or incident? We believe there are near misses that are not reported and that many have valuable learning potential but have not been investigated. Note that you may not know if there have been near misses, unplanned interventions or whether you were just lucky unless you investigate to find out.
Reflekt has also developed a methodology for learning from success. Many companies have successes, however because they do not understand why they have success they find it difficult to repeat these successes. Reflekt’s methodology starts with how to define and then identify a success. We have developed a success causation model and generic direct and underlying causes that can be used to describe the success and attribute these to key elements in the management of the company/project/activity.