Hey Paul,

Here are a couple of other points you might want to consider:

An incident usually starts when some activity or step thereof diverges from our expectations.  The consequences may result in a loss, or maybe not. Incidents without loss (near-misses) are key to identifying problems occurring in an operation and must be reported and acted upon (if preventable & significant) if it is to be prevented in the future.  Unfortunately, people are often concerned with reputation damage, or in some cases repercussions, so they often go unreported. Basing your culture on no-jeopardy reporting and reward/recognition for reporting will help reduce repeat incidents, assuming the problem reported is addressed.

Some research has indicated a typical person tends to make as many as 5 to 10 errors per hour. Most go unnoticed and have no discernable consequences.  But consider for a moment if a person works 2080 hours in a year; that would be 10,400 human errors/person on the low side. Have 100 people? Make that 1,040,000 errors per year. (And some human errors are unpreventable).  Some of these errors will result in incidents, and a smaller subset in loss. The very perception that all unplanned events can be prevented is na=C3-ve, but management is usually sincere in saying it. So zero incidents is not reality, perhaps zero injuries (if you're lucky) or some target loss amount is a better goal.

The next very real problem is that people are not as good at fixing problems as they believe.  It isn't their fault, it's a human perception problem.  We get distracted by the damage and/or injuries and most of the time fail to actually fix what went wrong. In reviewing countless incident investigations, about 75% of the time the thing that went wrong was not prevented from happening again. (The events just hadn't repeated yet, & some were fatality events!). Rather, safeguards were provided instead. I recall in a course in college (a lifetime ago) the instructor stating "identify what happened and safeguard it, then if it happens again loss will be minimized." My goal is always to prevent the unplanned event from happening again, thus eliminating potential consequences. But we, as people, do not inherently do this. It is actually quite a wake-up call to realize this happens.

Of course, there are times all you can do is reduce the probability of an event reoccurring to an acceptable level, and sometimes events are not worth preventing (no possibility of injury or loss).

There is a consulting company that helps organizations recognize and address these issues. (not mine)

Best of luck!

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