(56m) Finding and Presenting Latent Causes of Small Incidents and Near Misses

Small incident and near miss investigations are commonly poorly executed in industry. This presentation briefly reviews commonly observed problems with these investigations, then presents human factors that support poor performance in organizations. Following this, the presentation focuses on means to effectively identify latent human causes that set the stage for the small incident or near miss, using common tools available to any investigator. Finally, the presentation focuses on the human factors that prevent management from understanding and accepting the latent causes that were identified, and presents methods to effectively present the results of an investigation in a manner that encourages adoption of recommended actions.