Abstract
Within BASF there is a large variety of tools connected to learning from accidents or incidents like incident investigation, root cause analysis, databases, short notice communication, detailed communication about severe incidents or accumulation of similar incidents and so for. The critical topic in every incident analysis is to get the real root causes for developing the most wide reaching corrective actions. If the root causes are not addressed but the investigation scrapes only at the surface, than the measures can also not be adequate. This may be the case e.g. if only the personal performance of the injured person is addressed and management systems like a missing hazard assessment are not scrutinized.
Therefore, the BASF method of root cause analysis will be presented. This includes also best practices for a good incident investigation which is the basis for all root cause discussions.
An evaluation – applied to LTIs (lost time injuries) - shows that there is room for improvement with respect to root cause analysis: In some cases the root cause analysis is not done or documented at all and in other cases the focus is only on “personal performance” but other root causes could and should also have been addressed but were missing.
For further improvement of the root cause analysis special training programs have been developed which can be used either by occupational safety as well as by process safety.
Therefore, a good basis is laid for the future incident communication. Immediate causes will be replaced by real root causes and the corresponding measures will develop their full learning potential – keeping in mind that human beings will fail and this cannot be stopped, but minimized by sharing the real learnings of our past failures.
