Proactima has reviewed the investigation reports from 18 serious incidents to look for commonalities in the incidents and investigations, and to examine if the investigations are appropriate for highlighting learning points that may help improve industry practice and better defend against accidents.
In the work, the need arose for a framework within which to compare incidents and investigations. As part of the study, a framework for thematic analysis was therefore established, as recommended by the Safety Forum in their report on learning from incidents (2019).
The framework allows the mapping of incidents and investigations within a common structure, based on regulatory requirements and the PSA's barrier memorandum (2017).
The framework is not an investigative methodology, but a tool for structuring causal relationships in order to raise awareness thereof and to examine the incidents from a different perspective. The framework helps raise the investigations out of the incident-specific and into a broader context, ideally transcending both the facility and the individual company. Through thematic analysis of multiple incidents, it is possible to investigate whether they elucidate more systemic causes.
Use of the framework may
- help defend more effectively against accidents through improved investigative practice. Better investigative practice is an important precondition for improving learning.
- provide better criteria for criticality assessments of incidents. This may help improve the selection of incidents to be investigated, and thus prevent important lessons from being disregarded.
- improve understanding why an incident may arise and why the same types of incidents recur.
The report is available in Norwegian only.
Strong focus on learning from incidents
From 2022, the government has earmarked funds to strengthen and enhance the Petroleum Safety Authority Norway’s work on following up serious incidents. The PSA is to spend NOK 17 million per annum on strengthening and enhancing the follow-up of serious incidents in the petroleum industry.
Find out more here: Big drive for better follow-up