3521 Tripod lite: A ‘lite’ tool for investigating simple incidents, events and near misses

Overview:

This publication is free to download.  Register or log in, then click 'download'.

Note: this will download a document 'landing page' that includes a link to both the PDF and Excel versions of Tripod lite.

Investigations into serious incidents often reveal that the causes could have been identified with more systematic analysis of previous simple and less severe incidents or near misses. However, it is impractical to investigate and analyse every event in the same depth as more serious incidents, so weak signals and learning opportunities are missed.

Tripod lite is a basic but powerful tool to identify systematic issues from less severe events in a short time scale, and in a way that amplifies those weak signals. It is a simple to use and robust incident analysis tool that can easily be applied by supervisors, local managers and investigators who need to quickly investigate and learn from ‘simpler’ events (i.e. incidents and near misses that are easily described and modelled).

A Tripod lite analysis helps an incident investigator to uncover:

1. What happened? The events that led to an incident.
2. How did it happen? The barriers/safeguards that should have been in place to prevent the incident, but failed.
3. Why did it happen? What caused the barriers to fail?

Tripod lite is based on a simplified version of Tripod Beta, and has been designed specifically for quick investigations of 'simple' incidents and near misses.  We set out to create a self contained investigation tool with the following features:

• Free to use. Tripod lite is freely available as a download. Yes, really!
• Doesn't require special software to use. Tripod lite is available as a PDF or Excel file.
• Requires minimal training. However, some training is recommended, and we are developing a short online training course (expected release mid-2023).
• Self contained.  Tripod lite includes step by step instructions on how to carry out a simple investigation and analysis. It acts as the incident reporting form, the incident analysis, and allows you to record recommendations.  Tripod lite could enhance or even replace your current incident reporting form.
• Quick to use. A Tripod lite investigation can be completed in as little as 2 hours.
• Amplifies weak signals. Tripod lite has been designed so that events can be reported and investigated consistently. Standardised options are used to categorise causes. You can then easily export the findings from multiple Tripod lite investigations to find common performance influencing factors, human behaviours, and organisational weaknesses. Imagine what you could learn from 1000 near misses!
• Can be used throughout the organisation, at all levels. We've designed Tripod lite to be used by anybody, including supervisors, managers as well as trained investigators.

Tripod lite is an interactive PDF. It contains a barrier-based visual representation of the incident (a Swiss cheese model) which the user can populate electronically or by hand in a printout. By clicking on the numbered steps in the diagram, the tool provides all the guidance necessary to carry out an incident analysis. Drop down categories can be used to classify causes for multi-incident analysis, and the tool allows you to make recommendations for failed barriers, and short- and long-term recommendations to address the causes.

There is also a Microsoft Excel spreadsheet version, which offers more flexibility for more advanced users, including the ability to customise the drop-down menus and record more barriers and causes.