COMET Participant Manual Content Rev - 1

DISCOVER ANALYSE ACTION
KEY DEFINITIONS
COMET FACTOR
“A COMET FACTOR IS A HUMAN ERROR, ORGANIZATIONAL SHORTFALL OR

SYSTEM/EQUIPMENT/PROCESS FAILURE THAT DIRECTLY CONTRIBUTED TO THE
INCIDENT OR MADE MATTERS WORSE.”
ROOT CAUSE
“THE CAUSE OF A PROBLEM WHICH, IF ADDRESSED, WILL PREVENT OR

SIGNIFICANTLY REDUCE THE LIKELIHOOD OF RECURRENCE OF THAT PROBLEM
OR SIMILAR PROBLEMS”
INTRODUCTION
Welcome to your COMET incident investigation and root cause analysis training course. You will be
taught the key stages of incident investigation, from managing the incident scene through to the
interviewing of witnesses. We will thereafter move onto root cause analysis including the
identification of COMET factors and root causes, before closing out with the implementation of
effective preventive actions.
This course has been designed to be as interactive as possible. You will work in teams to fully
investigate and analyse a case study which will be provided by your instructor.
We hope you enjoy your COMET training course and remember, your instructor is an experienced
investigator and root cause analysis expert, so don’t be afraid to challenge and ask plenty questions
along the way.
WHAT IS COMET?
COMET is a toolset and learning experience to get to the ROOT CAUSES of problems quickly and
efficiently. The process is broken down into three main phases; Discover, Analyse and Action.
The Discovery phase covers proven INVESTIGATION techniques grounded in forensic practices to
generate the optimum input data. Specifically:
• SID:Grid
• Scene Management & Equipment
• Documents
• Human Factors
• Witness interviews
• Barrier and Change evaluation
The Analyse phase includes unique COMET ROOTMAPS to identify root causes of significant problems.
Specifically:
• COMET Factor identification

• Root Cause identification
Finally, the Action phase assists in creating PREVENTIVE ACTIONS to deal with the root causes
preventing repeat failure. Specifically:
• SMARTER actions
• Preventive Action Prompt guide
Copyright © 2020 STC Global Ltd. All Rights Reserved.

CONTENTS
INTRODUCTION
YOUR WORLD
DISCOVER
SID:Grid 01
SCENE MANAGEMENT & EQUIPMENT 05
DOCUMENTS 13
HUMAN FACTORS 15
WITNESS INTERVIEWS 19
BARRIER EVALUATION 32
CHANGE EVALUATION 38
ANALYSE
COMET FACTORS 39
ROOT CAUSES 44
COMET ROOT MAPS 47
ROOT CAUSE GRID 58
ACTION
PREVENTIVE ACTIONS 59
PREVENTIVE ACTION PROMPTS 62
ADDITIONAL MATERIALS (SEE TABS)
INVESTIGATION PROMPT CARDS
APPENDICES
COMET LITE

DISCOVER

01
SID:Grid
(SIGNIFICANT INVESTIGATION DATA:Grid)

02 HOW TO BUILD A SID:Grid
The SID:Grid is designed to assist the investigator to understand what took place in the lead up to,
during and following the incident. To achieve this it is necessary to gather all the relevant and
significant information related to the incident and use it to develop a chronological sequence of
events. Additional supporting data is then added to build the bigger picture and add context to the
events that have taken place.
The SID:Grid is an excellent tool to visually display this information in an easy to comprehend and
organised manner. The construction of a SID:Grid is a straightforward process involving the
application of various post-it stickies to a wall-chart or directly onto an electronic version.
An added benefit of creating a SID:Grid is that it encourages the investigation team to participate
in healthy discussion, debate and challenge during the information gathering stage, thus avoiding
the potentially biased or ‘blinkered’ approach of individual investigators. When complete, the
SID:Grid assists the investigator to identify gaps in the investigation and take steps to fill them.
Building a SID:Grid is a simple four step process:
11 22 33 44
IDENTIFY THE OUTLINE THE ADD SUPPORTING CONTINUALLY
IDENTIFY
INCIDENT ANDTHE OUTLINE
SEQUENCE THE
OF EVENTS DATAADD SUPPORTING
BELOW EACH CONTINUALLY
REVIEW FOR ANY
INCIDENT
HIGHLIGHT AND ALONG
IT IN RED SEQUENCE OF
THE TOP EVENTS
LINE DATA BELOW EACH
EVENT REVIEW
GAPS FOR ANY
HIGHLIGHT IT IN RED ALONG THE TOP LINE EVENT GAPS
STEP 1 – IDENTIFY THE INCIDENT AND HIGHLIGHT IT IN RED
Highlighting the incident in red will help to differentiate it from the other events once you move onto
step 2. The incident is what triggered the investigation and typically will be the worst thing that
happened. However it is important to note that the SID:Grid should not end at the incident but also
include the response to it until stability or normality is restored.
1 2 3 4
INCIDENT AND SEQUENCE OF EVENTS DATA BELOW EACH REVIEW FOR ANY
HOW TO BUILD A SID:Grid 03
STEP 2 – OUTLINE THE SEQUENCE OF EVENTS ALONG THE TOP LINE
The sequence of events tells the story of what happened leading up to, during and after the incident.
An event is short and factual usually detailing what someone or something did. Begin with events
around TASK PLANNING and PREPARATION. Work through the events of TASK PERFORMANCE leading
up to the incident and through events surrounding RESPONSE and RECOVERY. The description of
each event only requires sufficient detail to indicate the nature of the action and distinguish it from other
events. In some cases a number of events can occur simultaneously, so wherever possible add the
time and date to the timeline.
STEP 3 – ADD SUPPORTING DATA BELOW EACH EVENT
Once the incident has been identified and the sequence of events is complete, it is time to build on
the SID:Grid and add the supporting data that helps the investigator understand the context of events.
The more data on the SID:Grid, the more definitive the picture of the investigation. Whilst the sequence
of events on the timeline line consists of action steps, supporting data is passive information
typically surrounding:
- Scene Management & Equipment - Witnesses

- Documentation - Interview Information
- Human Factors
For each event take time to consult the Human Factors Guide and investigation prompt sheets to
stimulate consideration of information/data worth adding to the investigative picture. Write the
information on “post its” and place them on the grid below the relevant event. Some of the data
added will be generic and not related to specific events so place it in an appropriate position on the
grid for future reference.
1 2 3 4

04 HOW TO BUILD A SID:Grid
STEP 4 – CONTINUALLY REVIEW FOR ANY GAPS
The SID:Grid is a living document that is the cornerstone of the investigation. It is reviewed on an
ongoing basis throughout the investigation to identify if there is information missing that could help
explain what has happened and if there are any obvious gaps. If knowledge gaps are identified, the
investigator will require to go back and ask more questions or dig deeper. This is perfectly normal
and should not be seen as a weakness in the investigation as it actually provides reassurance that the
investigation has been thorough. Even the most experienced investigators may initially overlook
something which turns out to be important.
As questions are answered and the gaps are filled, add any new information gleaned to the SID:Grid
but remember, no matter how thorough the investigation, it is not always possible to fill all of the
gaps and there are times when it just has to be accepted that the information sought is not available.
This is often the case in a lone worker incident.
When a decision has been taken that all relevant available information has been gathered and the
investigation is complete, the SID:Grid will feed the COMET analysis process to identify the
COMET FACTORS and ROOT CAUSES of the incident.
Further tools to close out the investigation will be covered within Barrier Evaluation and
Change Evaluation.
SEQUENCE OF EVENTS PRE INCIDENT INCIDENT POST INCIDENT

EVENTS EVENTS &
RESPONSE
SUPPORTING DATA

05
SCENE MANAGEMENT
& EQUIPMENT
SAFE STABLE SECURE SURVEY
TOOLS MACHINERY PARTS, PPE

FITTINGS
& MATERIALS

06 SCENE MANAGEMENT
The primary objectives at the scene of every incident are to make the area safe; treat injuries or the
symptoms of ill health and minimise damage to the environment, the site and equipment. Local
incident response plans and procedures take precedence in every case. When the primary objectives
have been achieved, the extent of the scene should be assessed and the relevant area secured and
preserved. This is in line with the SAFE, STABLE, SECURE, SURVEY methodology.
An examination of the scene proportionate to the incident should then be carried out to gather and record
all available evidence that will inform the investigator to understand the circumstances of the incident itself.
It should be borne in mind that once the examination is complete and normal operations have been resumed,
any evidence that was not gathered during the examination may be lost to the investigator. It is always better
to err on the side of caution from the outset and preserve everything that may subsequently have a bearing
on the investigation.
For accuracy and future reference record any items removed from the scene.
NOTE: It is recognised that on occasion the investigation team may not have ready access to the scene
and may have to delegate scene management responsibilities to site personnel.
RECORDING THE SCENE
WHAT CHANGED
Whichever method(s) are used to record the incident scene it is critical to record whether or not it is of the
incident scene as it was in its original state immediately after the incident. If the scene has changed from
its original state following the incident, the changes should be noted to provide context. For example it is
important to understand what steps first responders took to make the scene safe. Were power supplies
switched off? Were valves closed? Was lighting switched on? Were spillages cleaned up? Was equipment
moved? Did they introduce anything to the scene?
CCTV
Early consideration should be given to the preservation of CCTV images that capture the scene and
may have recorded the incident or events leading up to or following it. Although not directly related to the
incident under investigation, historic CCTV footage and photographs may be of relevance in the wider
context of the investigation if changes to the working environment later feature as a potential contributory
factor.

SCENE MANAGEMENT 07
VIDEO/PHOTO/SKETCHES
There are various options open to capture the scene using photographs/digital images, video and
sketches/diagrams. Each has its own merits and often a combination of the different techniques
produces the best record. When using photographs and video, close up images should always include
a scale measure for perspective and sketches/diagrams should incorporate relevant measurements.
GENERAL GUIDANCE
The incident scene should also be assessed to determine whether or not the physical layout may
have contributed to the incident in any way or whether the potential impact of environmental
conditions is relevant.
Witness evidence adds valuable context especially when the scene has changed post incident prior
to examination. It assists in identifying prevailing environmental conditions and is also integral to
identifying any other concurrent activity in the environs of the incident that may have contributed
to it or distracted those involved in the activity that led to the incident.
Where the scene is spread over a larger area consideration should be given to obtaining existing site,
facility and floor plans if they add value to the overall understanding of the incident.
RECOVERY OF PHYSICAL EVIDENCE
First consideration in every case is safety in the recovery process. Depending on the circumstances,
entry to the scene and the recovery of physical evidence may require to be formally risk assessed.
Physical evidence is anything recovered at the scene of the incident or elsewhere that had some
bearing on the events leading up to, during or immediately following the incident. Typically it will
take the form of equipment taken for further examination and assessment. All items seized should
be securely and safely handled and stored and any subsequent movement for examination purposes
recorded to protect the integrity of the recovery process.
TOP TIP
ALWAYS REFER TO THE SCENE

MANAGEMENT PROMPT SHEET

08 EQUIPMENT
For investigation purposes equipment can be sub-divided into four categories:
TOOLS MACHINERY PARTS, FITTINGS PPE

& MATERIALS
In most cases, equipment will feature as an element of incident investigation either due to the
failure of the equipment itself or poor operator interface. Failures usually occur during the early
stages of the life cycle (teething problems) or near end of life (worn out). Failures that occur mid-life
cycle, are usually an indication that something has changed eg operating regime / maintenance
programme etc.
EQUIPMENT INVESTIGATION ROUTE

failure rate
There is a natural sequence when

investigating equipment related issues.
The circumstances of each incident dictates
wear in steady state wear out
the extent of investigation required. The
main consideration in determining this is proportionality. The sequence begins by exploring the most
recent data available and then extends back through the more historical stages in the life-cycle, to try
and identify issues of relevance to the investigation.
History Storage/
Modification Interface Maintenance Installation Procurement Design
Transport
Consider the information set out in the slides on the following page and make reference to the
Equipment prompt sheet when developing lines of investigation.
In every case, where equipment has been identified as a factor/potential factor in the investigation,
a full examination of all equipment used to perform incident related activity should be carried out
by a qualified person and the results/assessments should be included in the Incident Report.
TOP TIP
ALWAYS REFER TO THE

EQUIPMENT PROMPT SHEET

EQUIPMENT INVESTIGATION ROUTE 09
Storage/
History Modification Interface Maintenance Installation Procurement Design
transport
• Has this happened before?
• Is there a failure history with similar equipment?
• Could this failure extend beyond the immediate asset?
Storage/
transport
• Has the equipment been modified since design?
• Has anything changed or been modified in the process where the

equipment is being utilised?
• If so, was there appropriate Management of Change (MOC)?

10 EQUIPMENT INVESTIGATION ROUTE
Storage/
transport
• Was Planning / Preparation of the equipment operation adequate?
• Was the operator of the equipment competent?
• Was there adherence to standard operating procedures?
Storage/
transport
• Is there a maintenance regime in place?
• Is it fit for purpose?
• Has it been followed and recorded?

EQUIPMENT INVESTIGATION ROUTE 11
Storage/
transport
• Was there sufficient pre job planning of the installation?
• Did this involve competent personnel?
• Was sufficient time scheduled for the installation?
Storage/
transport
• Is there unexplained damage/degradation to the equipment?
• Could poor storage be a factor? e.g. corrosion
• Could the transportation process be a factor? e.g. damage in transit

12 EQUIPMENT INVESTIGATION ROUTE
Storage/
transport
• Does a Procurement Process exist?
• Has it been followed correctly?
• Are there any local/site deviations to the central

procurement process?
Storage/
transport
• Is the incident sufficiently serious to justify investigating any

design issues?
• Can design data be accessed?
• Critical incidents – no other explanation?

13
DOCUMENTS
Hard Copy Electronic Digital

14 DOCUMENTS
WHY ARE DOCUMENTS IMPORTANT?
They provide historical references, can validate or disprove information learned from other sources,
inform audits and they often identify witnesses involved in the planning, authorisation and supervision
process. Documents relevant to the incident are dictated by circumstances however some common
examples for review include:
• REGULATORY OR ADVISORY:
HSE/OSHA Guidance, Industry Standards/Alerts
• ACTIVITY SPECIFIC:
Permit to Work, Risk Assessment, JSA, Toolbox Talks, Safe System of Work (SSoW)
• PERSONNEL/HR:
Employment History, Training Records, Competency and Accreditation
• EQUIPMENT:
Manufacturers Guidance, Maintenance History, Modifications, MOC
• ORGANISATIONAL/MANAGEMENT:
Policies, Procedures, Instruction, Guidance and Standards (PPIG)
At an early stage in any investigation, consideration should be given to securing the documentary
evidence required. A recovery plan should be compiled and documents taken possession of and
securely stored. Each document should be thoroughly examined and consideration should be given to
its integrity and provenance.
Documents should be reviewed at regular stages to assess the validity of each item in relation to
the investigation and if required, decisions taken about retention or return.
Always consider the provenance of the documents reviewed during the investigation. If a document is
missing check the system. Is it the only one missing? Is that a coincidence? Check for overwriting and
alterations, ask who made them, when they were made and why? Check the sequencing of numbered
documents – was it produced as an afterthought? Does the compilation or standard of it stand out or
differ from all similar documents in the file?
ANOMALIES
• Missing
• Overwriting
• Alterations
• Out of sequence
• Too good to be true!

15
HUMAN FACTORS
JOB
INDIVIDUAL
ORGANISATION

16 HUMAN FACTORS
WHAT IS HUMAN FACTORS?
Human failures are widely recognised across all industry sectors as being a frequent contributor to
incidents. Statistically 95% - 98% of incidents involve a lesser or greater degree of human error.
However, identifying `Human Error` alone as a root cause is not sufficient. An investigation needs to
uncover WHY the mistake or error occurred.
The investigation uncovers the mistakes whilst the root cause analysis uncovers the reasons behind the
mistakes.
Whilst not an absolute, the emergence of multiple similar violations or errors in an incident could well
reflect on an organisations safety culture and within COMET are referred to as `Systemic Root Causes`.
Conversely isolated violation or errors are more likely to be individual or team based involving in a singular
job or task.
In the course of a COMET investigation the investigator will explore human performance leading up to or
during the incident through 3 lenses which cover the investigative spectrum of Human Factors:
1) The Job or Task
2) The Individuals involved in Planning, Supervising or Performing the task or activity
3) The Organisation
See Appendix A - Human Factors Guide

HUMAN FACTORS 17
Job Factors Individual Factors
Failed controls/alarms? Skill or competence?
Distractions/interruptions? Fatigue or boredom?
Cramped Workspace? Team dynamics?
Poor tools/equipment? Morale issues?
Organisational Factors
Adequate PPIG?
Adequate Resourcing?
Communication?
Previous Incidents?
In order for a task or activity whether routine or more specialist/complex to succeed, the three Human Factor
`cogs`, above, require to work in harmony and complement each other. If one `cog` fails or becomes
dysfunctional the task or activity is likely to break down or falter and often this will lead to the incident under
investigation.
Consider in more detail
1) JOB OR TASK FACTORS
Here we consider the job or task itself. Has the work site been designed or laid out correctly?
Do difficult working conditions make successful completion of the job unrealistic for the workers?
Were environmental conditions different or worse than normal which impacted on the job?
Essentially, the job must be planned for correctly and carried out in the ideal working conditions.
Any shortcomings should be identified, with the critical question to be posed:
‘WAS THE JOB SET UP FOR SUCCESS OR FAILURE?’

18 HUMAN FACTORS
2) INDIVIDUAL FACTORS
Consideration must be given to those individuals involved in the activity in relation to their training,
experience and competence to undertake the activity in question. This links strongly with building their
Personnel Profile however is taken to the next level by also considering individuals work load and .
What is their relationship with colleagues? What is their relationship with Supervisors and Managers?
Personal circumstances should also be considered. This is potentially a sensitive area to delve into
however it can be vitally important. An individual’s personal or ‘home’ circumstances can have a huge
impact on their performance at work, irrespective of their competence and experience. Other personal
issues including fatigue, boredom can be factors.
3) ORGANISATIONAL FACTORS
The organisation has the overall responsibility to ensure an overarching safe system of work and that the
job or task is set up for success. When looking at the organisation, consideration should be given to
Management Systems, Policy and Procedures for specific tasks, failure to learn lessons and the overall
safety culture, among others.
20 QUESTION HUMAN FACTOR GUIDE
The 20 Question Human Factor Guide has been developed to assist the investigator performing an
investigation where human error exists either individually or in a team environment.
The guide, whilst not exhaustive, has been developed from decades of investigative experience and
academic research into what lies behind human error.
It has been sub-divided into the three categories discussed above and is an excellent resource
particularly when planning witness interviews.
It can also be used as a prompt when considering data during the building of the SID:Grid.

19
WITNESS INTERVIEWS
• WHO IS A WITNESS?
• KNOWING YOUR WITNESS
• PRISM
• QUESTIONING, LISTENING
& BODY LANGUAGE
• INTERVIEW CONTENT

20 WITNESS INTERVIEWS: WHO IS A WITNESS?
Invariably the interviewing of witnesses is an integral part of every incident investigation hence a
structured approach is key to success. The basic foundation upon which to develop an effective witness
interview strategy is an understanding of the witness’s relationship to the investigation. This understanding
helps inform the level and nature of the planning and preparation required to conduct a successful
interview and move the investigation forward.
Typically, witnesses fall into four categories:
A. DIRECT WITNESSES are the most obvious category and are those people who were in the vicinity
of the incident at the time; were involved in the planning, preparation, assessment or approval of the
activity; were in some way involved in the response to the incident. They will help you understand the
sequence of events leading up to the incident, the incident itself and what happened immediately after it.
B. SUBJECT MATTER WITNESSES have specialist knowledge in terms of equipment or process which
will help you understand the task being performed, the equipment in use and the human / machine
interface. Subject matter witnesses may also be used for post incident scene or equipment examination
such as process failure. Almost always the Subject Matter Witness will come from within the organisation
e.g. Electrical Technical Authority (TA)
C. MANAGEMENT WITNESSES provide the organisational knowledge to help you understand company
policy, procedures, instruction and guidance (PPIG). Such witnesses will provide valuable insight into
the company approach to safety, incident information instruction & guidance reporting and recording,
equipment procurement and maintenance, HR and training issues. A management witness may not be a
manager by job title, but someone with the authority & knowledge of the way in which the organisation
is managed.
D. EXPERT WITNESSES will be recognised for their qualifications, experience, expertise and knowledge
in a specific field. They analyse the information gathered during the investigation and provide expert
opinion based on their interpretation of the facts and circumstances presented. Typically an expert witness
will be external to the organisation. e.g. provision of a metallurgical examination report
WITNESS DYNAMICS
Recognising the category of witness to be interviewed

provides the basis upon which to begin to construct the
interview strategy, however there is a further dimension
that the investigator has to consider and plan for, the
ability and willingness of the witness to co-operate
with the investigation. See image to the right.
NOTE: The objective
is to move your
The better the understanding of where a witness falls
witness into the
on the axis, the better tailored the interview strategy willing and able
quadrant.
will be towards a successful outcome. The key to
gaining an understanding of the witness’s position is
effective Planning and Preparation which is the first
element of the PRISM Interview Model.
WITNESS INTERVIEWS: KNOWING YOUR WITNESS 21
Information regarding the personnel involved in the planning, supervision and performance of the activity
surrounding the incident is of relevance to the investigation, in order that an assessment can be made of
their capability, capacity and competence in the respective roles they fulfilled. Such information also
provides valuable context to witness perceptions surrounding what took place and the actions of other
people involved. Access to the information should always be in full consultation with Human Resource (HR)
professionals who will advise on legal issues, company policy and individual privacy rights. Proportionality
in respect of accessing sensitive personal data is a key consideration.
EMPLOYMENT/CONTRACTOR HISTORY
The length of time a person has been employed or contracted by the company and the roles performed
during that period of employment can provide some indication of their exposure to and familiarity with
organisational culture, policies and procedures as well as their own level of experience and knowledge of
the responsibilities of other workers allied to particular processes and activities. Consideration should
also be given to their wider industry experience.
TRAINING & COMPETENCE
It is important to assess whether the personnel involved in an incident had the knowledge and skills
required to perform the role or task they planned, performed or supervised. The level of information
required to make this assessment is dictated by the circumstances of the incident and could extend from
confirmation of induction and health and safety training for routine unskilled activities, through to
ratification of attendance on relevant training courses, validation of professional qualifications and
currency of certification.
PERSONAL RECORD
In addition to employment history and training, a diverse range of information contained in personal
records may be of relevance to an investigation such as:
• WORK RESTRICTIONS DUE TO IMPAIRMENT OR PHYSICAL CAPABILITY

• RELATED PERFORMANCE/CONDUCT ISSUES
Briefing HR on the circumstances surrounding the incident and tasking them to assess the relevance of
the information contained in the Personal Record is generally the best approach, however if particular
information arises in respect of an individual during an investigation that may have a bearing on the
outcome, a more direct specific approach may be required.
NOTE: This information is often sensitive and can rightly be difficult to source and should only be sought
if proportionate to do so.
HOW THEY WORK TOGETHER - TEAM DYNAMICS
The information previously referred to in this section centres on individuals, however, where relevant,
wider consideration should also be given to overall supervision, team performance and the prevailing
dynamics within the team in an attempt to assess whether or not this may have been a contributory
factor.
22 WITNESS INTERVIEWS: THE PRISM INTERVIEW MODEL
The recommended structured approach to an effective witness interview is utilising a model developed
for use by industry sector investigators based upon the acronym PRISM. It is a flexible model that
empowers the interviewer to adapt to the dynamics of any interview situation as it develops and
thereby allow it to be controlled in a positive way.
P PLANNING AND PREPARATION
At the early stages of an investigation while initial information is being gathered, planning and
preparation for witness interviews begins. Each piece of information gleaned contributes to the
knowledge of the investigator and may inform the approach to subsequent witness interviews.
Familiarity and complacency are often the greatest barriers to success. In areas of repetitive business,
there can be a tendency to base preparation on previous experience instead of tailoring it to the
specific task at hand. Although there are often common themes, there are also factors that make
every interview unique.
• WHO ARE YOU INTERVIEWING?
• WHY ARE YOU INTERVIEWING THEM?
• WHAT DO YOU ALREADY KNOW?
• WHAT DO YOU NEED TO KNOW?
Consideration of these questions is fundamental to the interview process. The temptation to treat
this stage as routine and proceed without giving it due consideration is tantamount to a ‘plan to fail’.
It need not be a complicated process, in fact, a simple approach will provide the foundation for a
successful interview. An interview plan should always be compiled. See Appendix B - Interview Planning
The more information available to inform the interview plan, the more productive the interview is likely
to be. At this planning stage the interviewer should refer to the SID:Grid as the information and gaps on
it will feed the planning process, as will reference to the prompt sheets and the Human Factors Guide.
See Appendix A - Human Factors Guide
Focus on setting themes and objectives and avoid simply writing out lists of questions. This allows
for a more flexible approach to the interview.

WITNESS INTERVIEWS: THE PRISM INTERVIEW MODEL 23
CONSIDER:
• Who is best placed to perform the interview in terms of knowledge, skills and availability?
This is particularly relevant where there is a technical aspect to the interview. 2 interviewers are preferred,
1 taking the lead and the 2nd taking notes.
• At what stage during the investigation will you be best prepared and most likely to gain the most from
the witness interview? Don’t rush in.
• Where is the most appropriate location to ensure you will not be disturbed and that the witness will feel
comfortable enough to fully participate in the interview? Don't simply opt for the most convenient location.
R RAPPORT BUILDING
The interview process commences the first instant the interviewer comes into contact with the witness.
An interview can be a stressful experience for witnesses therefore it is vital to create an environment
where they feel sufficiently comfortable to contribute and share information.
First impressions are crucial to communicate the value being placed on the contribution the witness has
to make. The appearance and demeanour of the interviewer are important but equally important are
the physical surroundings where the interview is to take place. They all make a statement about the
professionalism of the approach. One common reason why interviews fail is due to the interviewers
failure to prepare or by adopting an unprofessional approach.
The interview will progress more constructively and productively if the process holds no surprises for the
witness. A full explanation of the purpose of the interview, areas that will be covered and expectations
surrounding the contribution of the witness helps to build trust and secure buy-in. It also provides an
opportunity to gauge the witness’s attitude to the process, encourage dialogue to address any concerns
that could otherwise become barriers to progress. Once the witness is engaged, the interviewer can build
a baseline of how they present in normal circumstances. Identifying a sudden change in the witnesses
attitude and participation may be an indicator they have become uncomfortable with the questions and
no longer wish to co-operate.
I INFORMATION GATHERING
This is the stage where the interviewer benefits from the investment in planning and preparation, follows
the set objectives and gathers relevant information from the witness. The interviewer should begin with
the use of open questions designed to encourage a full, meaningful answer drawing on the witness’s own
knowledge of the incident or interpretation of it. Questioning techniques assist with the flow of information
from the witness to the interviewer.

24 WITNESS INTERVIEWS: THE PRISM INTERVIEW MODEL
The use of open-ended questions typically begin with words such as "Why" and "How", or phrases
such as "Tell me about...", encouraging the witness to open up and give their account.
As the interview progresses the interviewer may opt for more closed questions prompting yes/no or
short factual answers to elicit specific pieces of information from the witness, focus on particular areas
where additional information is required and check that the understanding of what the witness has
offered during the interview is correct.
During this stage, the interviewer should focus on collecting as much information as possible and
avoid challenging the witness about inaccuracies or ambiguities identified.
S SUMMARISE, PROBE AND CONFIRM
When the interviewer is satisfied that the witness has provided all the relevant information that they can
or are willing to contribute, the content has to be confirmed, expanded upon where possible, and any
ambiguities probed and clarified. It is at this stage that the real skill of the interviewer comes to the fore as
he/she takes control and works in partnership with the witness to help add important detail to the
information provided with the use of effective closed questions and probes.
Only when the interviewer is satisfied that the process has been exhausted and all relevant information has
been gathered, is it time for the interviewer and witness to agree the content of the interview, captured
in accurate notes.
MERGE AND EVALUATE

M
Step 1: Closing the interview…
• Ensure all the objectives of the interview plan have been met
• Answer questions and deal with any concerns
• Consider further involvement of the witness
• Discuss next steps and timescales
• Provide a point of contact
• Leave the door open for future contact
Step 2: Updating SID:Grid and evaluating new position…
• Merge what you have learned with the wider investigation

• Evaluate the updated position
• Has the interview introduced further lines of investigation?
• Where are the remaining gaps in the investigation?
• Do you need to consider re-interviewing the witness?

WITNESS INTERVIEWS: QUESTIONING, LISTENING & BODY LANGUAGE 25
FUNDAMENTAL PRINCIPLES
There are some fundamental considerations when conducting interviews.
• The interviewer should remain polite and professional at all times, language should be kept simple and
to the point with jargon and acronyms avoided wherever possible.
• Questions should be asked for a purpose, not for the sake of it, as it is the quality not the quantity of
questions that will shape the outcome of the interview.
• The witness needs time to understand and consider the question they have been asked before they
provide their answer, so pace is critical.
• The interviewer should keep interruptions to a minimum and focus on the aims of the interview.
• The interviewer should remain open minded at all times and prepare to deal with the interviewee
making an unexpected disclosure or taking interviews in an unanticipated direction.
TYPES OF QUESTIONS
Although there are many different types of questions, the investigative interview should aim to make
use of a combination of Open Questions, Closed Questions and Probes whilst avoiding the use of
counter-productive questions.
There are certain types of question that will have a negative influence on the interview, cause confusion,
prompt an answer that the witness thinks is expected of them or deters the witness from participating
altogether.
1. LEADING QUESTIONS - Questions which demonstrate an element of expectation by the interviewer

about what the answer will be and encourages the witness to respond accordingly, effectively planting
words in the mouth of the witness.
2. MULTIPLE QUESTIONS – Multiple questions asked consecutively without allowing the witness to
respond to any of them individually, confusing the witness and leaving the interviewer to try and interpret
the relevance of the answer?
3. HYPOTHETICAL QUESTIONS – Questions which ask the witness to make a response based on a
hypothetical situation.
4. PUT DOWNS – Questions which undermine and or belittle the witness and will likely elicit a negative
response .

26 WITNESS INTERVIEWS: QUESTIONING, LISTENING & BODY LANGUAGE
OPEN QUESTIONS
An open question is designed to encourage a full, meaningful answer using the witness’ own
knowledge and impressions. They typically begin with words such as "Why" and "How", or phrases
which will encourage the witness to share information.
Always try to begin an interview with an open question which allows the witness to provide, in their
own words, their version of events. Open questions can also be used at various appropriate points
during the interview when explaining something new.
Below are some examples:
Examples of Opening Questions

In your own words, please can you explain to me what happened on the
Opening question…
day of the incident…?
Additional… What else happened that day?
What did you do after the incident?
Can you explain what you mean by that?
Please can you explain the planning process for this type of task?
CLOSED QUESTIONS
Closed questions prompting yes/no or short factual answers are mainly used in the summarise, probe
and confirm section, of an interview to elicit specific pieces of information from the witness and gain
confirmation that your understanding of what the witness said is correct. Use closed questions at
intervals throughout the interview when you want to check you have your facts correct and also to
clarify specific pieces of information
Types of closed questions will vary depending on what you are looking to confirm.
Examples are given below:
Examples of Closed Questions
Closed questions… What time did you start work that day?
Additional… Was John also with you?
Who carried out the task briefing?
Were you wearing your hard hat?
Are you trained to do that task?

PROBES
Open questions generate extensive answers while closed questions generate specifics. In either case
the interviewer may wish to expand the detail around particular key areas and this is achieved by the
use of probes.
Examples of Useful Probes

Hand movements Positive & Encouraging
Encouraging noises and body language – minor
but powerful indications that the interviewer is
Posture / Seating Position Head movements
listening, understands and wants the witness to
continue. Expectant facial expressions
Use silence as a question or probe
Pausing – once the witness is talking they feel

3-4 seconds to allow witness to gather their thoughts
responsible for filling silences and that expectation
is reinforced by the non-verbal communication of
3-7 seconds to encourage witness to continue
the interviewer
More than 7 seconds is too long
Tell me more about...

Extension Statements – invitations to the
witness to add more detail to their previous Please continue...
response
“Let’s see if I have got this right.”
Summary – used at the end of a sequence of

“I just want to make sure I have understood what you
questions or when a particular theme of the
have said so far”
interview is being concluded to confirm content
and invite response
“If I have understood you right, you are saying.....”
Use of all of the foregoing probes demonstrate to the

Active Listening – Used throughout the interview witness that the interviewer is paying attention and is
to demonstrate to the witness that the interested in what the witness has to say. That interest
information being provided is being received, indicates the importance of the information the witness is
understood and is important. providing and that in itself encourages the witness to add
detail to their input.
Using productive questioning techniques and communicates a sense of professionalism to the witness
and instils confidence in the interview process. The clear communication channels that are then
developed facilitate the accurate exchange of detailed information and a positive contribution to the
overall investigation.

Active Listening is equally as important as asking effective questions. It has already been referred to as
a probe in its own right and is an important element of the interview process.
There are a variety of barriers that get in the way of active listening. Some very basic environmental
factors surrounding unnecessary interruptions, background noise, physical distractions and personal
discomfort can impact significantly on the ability of both the interviewer and witness to listen properly,
so every effort should be made to minimise them.
Pressure of other activities and demands can lead to a lack of patience or interest by the interviewer
and has the potential to result in important information being missed. Equally if the interviewer has
already made up their mind about the outcome of the investigation prior to the interview, selective
hearing can take place and genuine information can be missed.
The witness will lose concentration if the interviewer uses language / messages that are too long or
complex, if they proceed too quickly or if they indicate a lack of interest in the answers / information
being provided.
FUNDAMENTAL PRINCIPLES
The listening process requires the interviewer to keep an open mind and absorb everything that is
being said. It allows them to pick out important messages being delivered by the witness, use verbal
and non-verbal communication to indicate that they have been understood and then question and
probe the content to expand the detail around them.
BENEFITS
Good listeners build productive relationships, inspire witnesses to communicate and gather more
information during the interview process.

Effective communication is the foundation of successful relationships, both personally and professionally,
and research demonstrates that body language is a very important aspect of this. It has a number of
elements that can individually or collectively have a significant impact during the interview.
The ability to understand and use body language productively is a powerful tool that helps the interviewer
connect with others, express what they really mean, navigate challenging situations and build positive
relationships.
Furthermore, being able to interpret a witness’s body language is advantageous and a skill that can be
developed over time, however a self-aware interviewer with the ability to pro actively use and exercise an
element of control over their own body language is equally as important in terms of achieving
the key interview objectives.
Body Language has several functions:
• IT CAN REPLACE SPEECH
• IT CAN COMPLEMENT SPEECH
• IT CAN BE USED TO REINFORCE WHAT IS BEING SAID
• IT ACTS AS A SOURCE OF FEEDBACK

The basic components of body language are:
APPEARANCE – includes clothing, professionalism and anything else that provides visual messages
to other people. The manner in which you present yourself, especially at an initial meeting, leaves a
lasting impression.
POSTURE – includes how you hold your head, position yourself and behave whilst interviewing. Avoid
slumping your shoulders and appearing disinterested.
POSITIONING – people are influenced by the distance between each other when communicating and
also by the height difference and angle of approach. Avoid standing over people which can appear
aggressive. Ensure the interview room is setup fairly and comfortably.
GESTURES – use of hand gestures to emphasise a key point during a question or statement. Be aware
of cultural interpretation of gestures.
FACIAL EXPRESSIONS – the face is a major source of expression when communicating with others.
You can smile, frown, remain neutral, show anger, show disgust, indicate you want to speak, and show
interest. Be aware of your facial expressions to ensure that you don’t unnecessarily influence or
distract the witness.
EYES – the eyes are often the first element of body language others see or notice. Be aware of potential
cultural issues, however typically speaking, making regular eye contact is positive and demonstrates
your confidence and interest.
MOVEMENT – movement, whether using the entire body or just part of it is both flexible and
commanding. For instance, moving toward the witness may send a message of dominance or
assertiveness, while moving away from the witness may send a message of avoidance, submission, or
simply bringing the interaction to a close.
Learning about the key elements of body language and increasing personal awareness of them will
enhance the interviewers overall capability as a communicator and improve their ability to detect
abnormalities in a witness’s behaviour that the interviewer may wish to clarify.
NOTE: An awareness of body language fundamentals is useful knowledge in an interview context,

however be careful about placing too much emphasis on using this to assess or influence the
witness. In particular be very wary of using body language signals to assess the truthfulness or
otherwise of a witness.

WITNESS INTERVIEWS: INTERVIEW CONTENT 31
There is a significant difference between interview content noted by an investigator based on the
information gathered during a witness interview, and information compiled independently by a
witness and provided to the investigator. For the purposes of differentiating between them,
everything pre formal interview will be referred to as an Initial Witness Account (IWA).
An IWA is usually provided in response to an early request for information surrounding the
circumstances of the incident. IWAs can be provided in different ways, ranging from verbal accounts
at the scene, through to emails outlining knowledge/involvement and hand written accounts
compiled by the witness themselves. The information contained in them can be of great assistance
however in a thorough investigation it needs to be tested and built upon. They are however a
useful starting point for the interview planning process.
As previously referred to in the interview planning process, the interviewer will require to prepare
in advance for the interview. The interview record template provides the standardised format to
record the witness’s evidence and some basic guidance on the information that should be recorded.
See Appendix B - Interview Planning and also Appendix C Interview Record
Capturing witness information through note taking tends to be the most common method and is
perfectly acceptable, providing the notes are an accurate reflection of the interview, capture all
relevant information and are legible, as per the above guidance. This is why having two
interviewers is beneficial; one to lead the interview and ask questions, the second to take notes and
ensure nothing is missed from the overall interview plan. Notes taken during an interview should
be shared with the witness during the ‘summarise, probe and confirm’ phase of PRISM allowing
them to check content and sign if appropriate. The request to have the witness sign a statement or
notes is an organisational decision.

32
BARRIER EVALUATION
STEP 3 - IDENTIFY THE BARRIERS STEP 4 - IDENTIFY WHAT
STEP 1 - IDENTIFY HAZARD STEP 2 - IDENTIFY TARGET THAT SHOULD HAVE BEEN IN BARRIERS WERE EFFECTIVE,
PLACE FAILED AND MISSING
effective
failed
missing

BARRIER EVALUATION 33
The function of a BARRIER is to PREVENT an undesirable action from taking place or PROTECT
the system and its people from the consequences if it does occur.
Prevention barriers are designed to stop the initiating action or event from happening. For
example a isolation, guardrails, valves etc.
Protection barriers are designed to mitigate or reduce the consequences of the undesirable event.
For example PPE, spill containment, evacuation plans etc.
These barriers can be both active and/or passive and may exist in various forms. The classifications
are:
PHYSICAL: cages, containment, PPE, valves, walls

FUNCTIONAL: braking systems, interlocks, passwords
SYMBOLIC: alarms, colour/shape control coding, warning signs etc
NON-PHYSICAL: policies/procedures/instruction/guidance (PPIG), processes, supervision, training
PPIG refers to Policy, Procedure, Instruction, Guidance, the standards by which an organisation
operates.
By identifying these barriers and determining their effectiveness in relation to the incident we will
identify factors that potentially contributed to the incident which we will use to identify ROOT CAUSES
and inform preventive action plans.
BARRIER Evaluation is a quick and simple technique designed to assist in the development of the
SID:Grid. It is also a powerful tool to help understand barriers that failed or were missing, as well as
existing barriers that worked well, thus very important when developing any future Preventive Action
programme.
To conduct a BARRIER Evaluation use your knowledge and experience to draw up a list of the barriers
that should have been in place in any situation. You may also require task specific documentation
and subject matter expertise.
Then for each of the barriers identified determine which…
1 were effective 2 failed 3 were missing
…in either preventing an aspect of the incident occurring, or protecting, by reducing the consequences
of the incident.
The failed and missing barriers will also signpost mistakes which should feature on the SID:Grid
and will subsequently feed the Root Cause Analysis phase.

34 BARRIER EVALUATION
Incidents occur when a hazard comes into contact with a target. In all safe operations in the
workplace sensible planning ensures that barriers are put in place to mitigate the risk of the
hazard and the target coming together.
Errors, failures or shortfalls that lead to barriers which fail to work as intended or are missing
altogether are key to identifying factors that contributed to the incident.
The four classifications of barriers (physical, functional, symbolic, non-physical) are supported by
Complementing barriers and Humans barriers.
COMPLEMENTING BARRIERS
Barriers often complement each other to provide strength in depth, such as:
SPEEDING - Non-Physical (PPIG – Speed Limit), Symbolic (Road signs) and Physical (Speed Bumps)
PPE - Physical (The PPE itself) and Non-Physical (PPIG – PPE Policy and Training)
LOCK OUT/TAG OUT (LO/TO) - Physical (Valve or lock), Symbolic (Signage) and Non – Physical (PPIG
– Isolation Policy)
HUMANS AS BARRIERS
Occasionally, humans themselves fulfil the role of the barrier however it is more generally the
case that they play an integrated role in both the design and effectiveness (or otherwise) of the
barrier. Examples of human barriers are:
PHYSICAL BARRIER - Security presence, supervision etc
FUNCTIONAL BARRIER - Perform LO/TO, trigger alarm, follow procedures

HOW TO PERFORM BARRIER EVALUATION 35
There are four steps involved in performing a Barrier Evaluation. Populate the template
(See Appendix D - Barrier Evaluation) as per the 4 step instructions. The template contains helpful
prompts to aid the process.
STEP 1 – Identify the Hazard(s) associated with the task

which led to the incident and populate in the first column.
NOTE: If there is more than one hazard in play in the

incident, each may require separate Barrier Evaluation,
however identifying and evaluating the most
significant hazard relating to the incident may well
suffice.
STEP 2 – Identify the Target(s) and enter it/them

in the second column.
STEP 3 – Identify and list all the barriers that should have
been in place for the incident and list these in column
three. This step is essential to assess and compare what
barriers were actually in play when the incident occurred.
STEP 4 – Finally in column four evaluate the barriers as

effective, failed or missing.
NOTE: Once the Barrier Evaluation is complete, cross-refer your findings with the information
on the SID:Grid to make sure that the failed and missing barriers are highlighted.
36
CHANGE EVALUATION
EQUIPMENT TIME PEOPLE
Missing? Shortcut? Someone missing?
New? Scheduling? Someone different?
Modified? Pressure? Human Factors?
Weather? Policy? Maintenance?
Lighting/Noise? Procedure? Inspection?
Housekeeping? Productivity? Training?
Workplace setup? Performance? Supervision?
ENVIRONMENT MANAGEMENT REGIME

CHANGE EVALUATION 37
Change Evaluation, as with Barrier Evaluation, is a tool to be utilised towards the end of an investigation
and assists in bringing focus to those errors or failures in the planning and performance of the task or
activity which contributed to the incident.
Change Evaluation was built on the premise that if a routine or pre planned task or activity, which has
previously been performed successfully without any issues, unexpectedly results in an incident,
something in the lead up will have changed or have been done differently.
Identifying the adverse changes(s) is important information data and will assist greatly when performing
the subsequent Root Cause Analysis
A Change Evaluation considers the following six areas:
EQUIPMENT – Missing? New? Modified? Defective?
TIME – Shortcut? Scheduling? Pressure? Delays?
PEOPLE – Missing? Different? Team Dynamics? Resource Numbers?
ENVIRONMENT – Weather? Lighting/noise etc? Housekeeping? Workplace set up?
MANAGEMENT – Policy? Procedure? Productivity? Performance?
REGIME – Maintenance? Inspection? Training? Supervision?
Simply work through the six areas using the Change Evaluation tool (See Appendix E - Change Evaluation)
in order to identify any changes. In order to complete this successfully, the information gathering
process from the investigation must be completed. Similar to Barrier Evaluation, you may need to rely
on subject matter expertise to assist in the process. It is crucial however that you have a full
understanding of what happened during the task leading up to and including the incident. This will
allow you to make comparison to previous successful tasks and identify those changes. Access to task
specific documentation may also be required.

38 CHANGE EVALUATION GUIDANCE
When completing change evaluation the following guidance should also be adhered to:
The change identified should be unique to the particular task/activity/project under investigation
relating to the incident/unplanned event. Changes should not simply be generic, ‘normal’ conditions
or circumstances.
Furthermore these should have had an adverse impact on the task/activity/project.
It should be noted that changes could be sudden or gradual over a period of time. Its not just any
change!
NOTE: Once the Change Evaluation is complete, cross-refer your findings with the information
on the SID:Grid to make sure that the adverse changes are highlighted.

ANALYSE

39
COMET FACTORS
ANALYSE
ROOT CAUSES - STEP 2
COMET FACTORS - STEP 1

40 COMET FACTORS
A COMET FACTOR IS DEFINED AS...
“HUMAN ERROR,
ORGANISATIONAL SHORTFALL
OR SYSTEM/EQUIPMENT/PROCESS FAILURE...
...THAT DIRECTLY CONTRIBUTED TO THE INCIDENT

OR MADE MATTERS WORSE”.
OBJECTIVE
The first stage of the Analysis phase is the identification of what are known as COMET Factors. Once
1 2 3 4
identified the second stage of the analysis process is to take each COMET Factor through the 5 COMET
root maps to determine the ROOT CAUSES relating to the incident under investigation.

Communication Operating Management Equipment Training

Environment
IDENTIFYING COMET FACTORS
COMET Factors can be identified in a number of different ways however they have to meet the above
definition. Mistakes or failures that exist on the SID:Grid but did not directly contribute to the incident
or its consequences are NOT COMET Factors. They may however be what is known as Latent Factors
covered later in this section.
BARRIER & CHANGE EVALUATION FINDINGS
Important attention should be paid to the outcomes of Barrier and Change Evaluations. In most
instances, failed or missing barriers will by default meet the COMET Factor definition as will identified
adverse change(s). This emphasises the importance of Barrier and Change Evaluations as investigation
tools to either help identify or validate COMET Factors on the SID:Grid. However, the COMET Factor
definition should always be adhered to. Evaluation findings which DO NOT meet the definition will
become Latent Factors.

COMET FACTORS 41
SID:GRID SWEEP
Once evaluation findings have been considered a process known as a SID:Grid sweep is conducted to
identify any remaining COMET Factors. Each remaining event and data point on the SID:Grid is considered
in turn to assess whether or not it is a mistake, shortfall or failure that meets the COMET Factor definition.
Any events or data points identified as a COMET Factor should be highlighted with a CF.
1 2 3 4 1 2
It is a mandatory step of the process to assess each and every event and data point on the SID:Grid, as they
3
ENTIFY THE OUTLINE THE ADD SUPPORTING IDENTIFY THE OUTLINE THE ADD SUPPORTING
CIDENT AND
must all be identified.
SEQUENCE OF EVENTS
Missing or failing to identify a COMET Factor will
DATA BELOW EACH
undermine the
INCIDENT AND
quality of the Root
SEQUENCE OF EVENTS DATA BELOW EACH
IGHT IT IN RED Cause Analysis
ALONG THE TOP LINE and potentially
EVENT lead to lost opportunities for organisational improvement.
HIGHLIGHT IT IN RED However
ALONG THE TOP LINE COMET
EVENT
best practice advises that the typical number of CF’s per investigation sits between 2 & 7. This will ultimately
be determined by the incident/unplanned event circumstances.
Anything outwith these parameters should trigger a peer review.
NOTE: Be careful not to confuse COMET Factors with ROOT Causes. COMET Factors are WHAT
went wrong whilst ROOT Causes are WHY it went wrong
TOP TIP
COMET BEST PRACTICE ADVISES THE

TYPICAL NUMBER OF COMET FACTORS
PER INVESTIGATION IS BETWEEN 2 & 7

42 COMET FACTORS
UNDERSTANDING CAUSAL RELATIONSHIP
A well completed SID:Grid will often contain a number of events and data points which have what is
known as a ‘causal relationship’. This means they are all associated or related to the same issue
(error, shortfall or failure).
In these circumstances it is easy to fall into the trap of identifying all such events and data points as
COMET Factors however this is not best practice. The investigator should consider each such event
and data point individually to ascertain which one is the true COMET Factor.
This will be the actual error, shortfall or failure which led directly to the incident/unplanned event or
made matters worse. Often these events and data points with a causal relationship will configure
close together (adjacent) on the SID:Grid known as a ‘cluster’. In this instance to identify the true
COMET Factor ask the question ‘what was the direct consequence of this issue?’ to each individual
event and data point within the casual relationship. If the answer leads you to another event or data
point then this cannot yet be the COMET Factor. However when the answer leads you directly to the
incident then you have successfully identified the true COMET Factor within the casual relationship.
tly to the incident

leads direc
‘what was the

direct consequence
of this issue?’
TOP TIP
WHEN IDENTIFYING COMET FACTORS

ALWAYS CONSIDER EVALUATION
FINDINGS AND CF DEFINITION

COMET FACTORS 43
EXAMPLE 1
A process incident occurs leading to an environmental spill because an operative who was rushing to
complete the task failed to follow the valve sequence shut down checklist and closed the wrong valve.
COMET Factor No 1 – Operator closes the wrong valve V1 instead of V2
ROOT Cause No 1 – Intentional failure to follow procedures (PPIG) - OE1

ROOT Cause No 2 – Poor scheduling of task or activity – M6
(There may well be other associated Root Causes)
EXAMPLE 2
A safety incident occurs when a bolting contractor, untrained in the use of a hydraulic tool, handles it
incorrectly and it strikes his head. He was not wearing his hard hat as per procedures compounding
the injury. The area he was working in was dark and cramped
COMET Factor No 1 – Operator was operating the hydraulic wrench when it slipped and struck his head
ROOT Cause No 1 – Incorrect tool operation – OE6

ROOT Cause No 2 – Obstructed or restricted workspace – OE11
ROOT Cause No 3 – Working in adverse lighting conditions – OE14
ROOT Cause No 3 – Training not provided – T1
(There may well be other associated Root Causes)
WHAT IS A LATENT FACTOR?
A Latent Factor is a mistake, failure or shortfall identified during the investigation but has not directly
contributed to the incident or unplanned event. It could be described as a potential future
COMET FACTOR.
Investigations will often uncover Latent Factor not directly related to the incident or unplanned event
yet for the future benefit of the organisation, still requires action to be taken.
HOW TO DEAL WITH LATENT FACTORS
Latent Factors will typically be dealt with ‘off scope’ from the current investigation. On being identified,
a decision will need to be made as to how and when action will be taken. This decision will fall initially to
the Team Leader however ultimately will be the responsibility of the Incident Owner.
Guidance on dealing with Latent Factors can be sought from within the ‘Action’ phase of COMET, in the
very same fashion as building Preventive Actions for identified Root Causes.

44
ROOT CAUSES
ANALYSE
ROOT CAUSES - STEP 2
COMET FACTORS - STEP 1

ROOT CAUSES 45
DEFINITION: ‘THE CAUSE OF A PROBLEM WHICH, IF ADDRESSED, WILL PREVENT OR SIGNIFICANTLY

REDUCE THE LIKELIHOOD OR RECURRENCE OF THAT PROBLEM OR SIMILAR PROBLEMS’.
Objective
The second stage of the analysis process is to take all of the identified COMET Factors through each of
the 5 COMET Root Maps to identify associated ROOT CAUSES. Once all of the ROOT CAUSES have been
identified the ROOT CAUSE ANALYSIS process is complete. Next is the Action Phase where Preventive
Actions are built to eliminate the identified ROOT CAUSES and hopefully prevent repeat incidents,
failures or under performance.
HOW TO IDENTIFY ROOT CAUSES
The COMET system incorporates five Rootmaps, each designed to lead to possible ROOT CAUSES
within one or more of the five organisational categories where Root Causes exist:

Environment
The Rootmaps have been designed as sequential Q&A flowcharts. Each begins with a gateway question.
Answer ‘YES’ to the gateway question and you continue to the sub questions, answer ‘NO’ and you
continue to the next Root Map. All of the COMET FACTORS identified on the SID:Grid are taken through
the five Rootmaps one at a time. The answer to the gateway question in each Rootmap guides the
investigator through the process and dependant on the response based on the evidence being
considered directs them to select ROOT CAUSES from pre-determined lists. Each COMET FACTOR must
be taken fully through the Rootmaps. In total there are 62 possible specific ROOT CAUSES within COMET.
The following is an illustration of the Communication Rootmap:

46 ROOT CAUSES
When taking the COMET FACTORS through the Rootmaps it is important to remember the following:
• A COMET FACTOR will typically produce multiple ROOT CAUSES often across the five different categories.
• It is often the case that a COMET root cause analysis will uncover duplicate ROOT CAUSES from different
COMET FACTORS. Duplicate ROOT CAUSES from different COMET FACTORS may suggest that the problem is
more acute or systemic.
• If a question cannot be answered because there is insufficient data this could trigger the need to return to
the investigation phase. This is quite common and to be encouraged rather that continuing the analysis with
uncertain data.
• When answering the gateway questions it is vital that the response relates specifically to the individual
COMET FACTOR in question. It is very easy to stray into other COMET FACTORS when answering the
questions which will skew the outcome of the analysis. A disciplined approach is required.
• Answers required to be answered factually and evidence based. Never make assumption based decisions.
• To aid the selection and understanding of individual or multiple ROOT CAUSES from the pre-determined
Rootmap list, each has a root cause description which expands upon the text in the rootmap grouping. For
example root cause T1 has the text ‘No training provided’. The full T1 Root Cause Description reads ‘Did a
conscious organisational decision not to provide the individual with the requisite or specific training to
perform the task, role or activity lead to a mistake or a failure?’
• Each of the 62 specific ROOT CAUSES has its own unique identifier which, from an organisational
perspective, is useful for trending recurring or systemic ROOT CAUSES.
WHAT NEXT?
As and when ROOT CAUSES are identified for each individual COMET FACTOR it is important to record them
within the ROOT CAUSE Grid, an example of which is shown below. ROOT CAUSE(S)
Text T1
When all of the COMET FACTORS have been taken through CF2 Text C6 OE8 M3 E4
the Rootmaps, and the ROOT CAUSE Grid has been populated
COMET FACTOR
CF3 Text C6 OE4 M3 T1

the analysis is complete and it is time to move to the final
phase of the process which is to develop preventive actions. CF4 Text C6 OE4 OE8 M3 E4 T1
CF5 Text OE4 M3

TOP TIP
COMET BEST PRACTICE ADVISES THE

TYPICAL NUMBER OF ROOT CAUSES PER
COMET FACTOR IS BETWEEN 2 & 7.

47
COMET ROOTMAPS

48 COMET ROOTMAP: COMMUNICATION
Take each specific COMET FACTOR identified on your SID:Grid in turn and apply it to the set of
5 COMET ROOTMAPs. This will direct you to a group of ROOT CAUSES from which you can select
those which are relevant.
Note the ROOT CAUSES which relate to each specific COMET FACTOR in the ROOT CAUSE Grid.
Example C6
DID failure of written or verbal communication of

NO Policies, Procedures, Instruction or Guidance (PPIG),
or an absence of PPIG, contribute to this COMET
FACTOR?
NO Was the failure due to or related to written

communication?
C1 PPIG too complex or confusing
C2 PPIG factually incorrect
C3 PPIG wrong revision or not updated
C4 PPIG incomplete
C5 PPIG difficult to access by users
C6 No written PPIG for the task or activity
Was the failure due to or related to verbal

NO communication?
PPIG misunderstood due to cultural barriers,

C7 language difficulties or the use of jargon or acronyms
PPIG failed due to adverse environmental conditions
C8 such as noise / interference / interruption / weather
or other form of distraction
PPIG failed due to faulty physical
C9 communication system
PPIG failed due to missing, or absence of, or poor /
C10 insufficient verbal briefing / handover for a task or
activity, or during a shift change
go to OPERATING ENVIRONMENT

COMMUNICATION ROOT CAUSE DESCRIPTIONS 49
Did the content, complexity or length of any document lead to a mistake because it was not user friendly or the user
C1 found it hard to understand and / or confusing?
C2 Was the user misled by factually incorrect or inaccurate documents, prints or drawings? NOTE: Fabricated or falsified
documentation may require immediate disciplinary investigation.
C3 Was the document being used the wrong revision or otherwise not up to date?
Did a mistake occur because the PPIG was incomplete? Was something missing from the document that was
C4 required for the task or activity.
Did the user have difficulty finding, laying hands on, or gaining access to the relevant documentation because it
C5 was missing, or in a remote or inaccessible location? This may include e-documentation on a computer hard
drive or server.
C6 Was there no written PPIG in existence for the task or activity?
Was verbal communication misunderstood due to cultural barriers, language difficulties or the use of jargon
C7 or acronyms?
Did verbal communication fail, or result in poor comprehension or understanding, due to working in an adverse
C8 environment e.g. noise / interference / interruption / weather or any other form of distraction?
Was the intended message missed or misunderstood as a result of a failed, ineffective or poor radio, telephone or
tannoy communication, system or signal? NOTE: If the communications equipment itself was defective consider
C9 also ROOT CAUSES E10 - Non-existent or inadequate maintenance or inspection regime or E11 - Not maintained
or inspected in accordance with an approved maintenance or inspection regime.
Was a mistake the result of an absence of, poor or insufficient verbal briefing / handover for a task or activity, or
C10 during a shift change? NOTE: Also consider OE3 - Poor team dynamics, or a lack of situational awareness leading
to a hazard induced condition.

50 COMET ROOTMAP: OPERATING ENVIRONMENT
DID failure to adhere to PPIG, undesirable human

behaviour or poor organisational culture OR the
NO improper use / availability of tools, equipment OR
the lay out of the workspace, contribute to this
COMET FACTOR?
NO Was the failure due to or related to PPIG

adherence or undesirable human behaviour?
OE1 Failure to adhere to PPIG / taking shortcuts
OE2 Carelessness, horseplay or media device distraction
Poor team dynamics, or a lack of situational

OE3 awareness leading to a hazard induced condition
OE4 PPE not worn or used incorrectly
Improper / inadequate isolation or overriding of

OE5 safety systems or controls
Incorrect tool(s), equipment or machinery handling,

OE6 operation or selection
OE7 Substance Abuse
Was the failure due to or related to the improper

use or availability of tools, equipment or machinery,
NO the set up / lay out of the workspace or the existing
culture in the workplace?
Change in the setup or layout affecting

OE8 equipment operating environment
Confusing / inadequate controls / displays / labels /

OE9 alarms / instrumentation or signage
OE10 Poor housekeeping
Obstructed or restricted workplace / hazard

OE11 inducing conditions
OE12 Poor organisational culture or safety culture
Correct tools, equipment, PPE or machinery

OE13 not available
Working in adverse lighting/temperature/ventilation/

OE14 noise environment/severe weather conditions
go to MANAGEMENT

OPERATING ENVIRONMENT ROOT CAUSE DESCRIPTIONS 51
OE1 Was this failure an intentional or unintentional deviation from PPIG, or the result of someone taking a shortcut?
Did carelessness, engaging in inappropriate horseplay, or distraction through the use of a media device affect the
OE2 performance of the task OR was the worker or work party distracted by others in the vicinity indulging in such
practices?
Did poor team dynamics, including team communication and engagement, or a lack of situational awareness
OE3 lead to a hazard inducing condition?
Did failure to wear the correct PPE, the wearing of it only in part, or wearing it improperly, lead to injury or other
OE4 consequence? NOTE: If PPE to be worn was not available the root cause is found at OE13.
Did unintentional or deliberate overriding, bypassing or the disabling of a safety control, LO/TO or LO/LC device
result in a failure? Was no isolation of equipment conducted in terms of LO/TO or LO/LC, or was the isolation
OE5 inadequate to ensure safety from sources of energy? Was an error made during the process of removing isolations
and restoring sources of energy?
Was / were the tool(s), equipment, or machinery used for the task or activity inappropriate, improperly selected,
OE6 incorrectly operated or mishandled? NOTE: If the correct or most suitable tool, equipment or machinery was not
available for the worker or operator to make use of, then the root cause should be OE13.
Was the capability of the worker or operator to perform the task or activity impaired due to substance abuse,
e.g. illegal drugs, alcohol or any other substance that has adverse physical or psychological consequences? NOTE:
This could also include misuse of legal or prescribed medication where known side effects are expected in terms of
OE7 inability to drive or operate tools, equipment or machinery, OR where the worker or operator has failed to declare
the use of such medicine. If no substance abuse policy exists, also consider ROOT CAUSE M7 - PPIG does not exist
or is inadequate or inaccurate.
Did unplanned or unexpected change in the set up or lay out of the workplace or jobsite lead to an error because
OE8 a worker or operator was unfamiliar with, or unaware of, the changes including the positioning of equipment?
Was an error the result of a worker or operator being confused, misled or becoming disorientated, due to
inadequate controls / displays / labels / alarms / instrumentation, or signage? e.g. poor human-machine interface.
OE9 NOTE: If the issue arose because the worker / operator struggled physically to operate the equipment or to take
readings, consider the arrangement / placement of the controls or displays etc. and consider ROOT CAUSE E1 –
Flawed Design, or E13 – Unauthorised or flawed modification of equipment.
Was an error or failure the result of poor housekeeping in the workplace or jobsite, including slips, trips and falls
OE10 due to clutter or slippery / wet surfaces?
Did an error, failure or injury occur because a worker or operator experienced difficulty in working in a tight or
otherwise constrained area and / or was unable to perform the task or activity properly or was obstructed in
OE11 doing so, because ease of movement or normal working capability was restricted or adversely affected OR because
the set up / layout led to hazard inducing conditions?
Was the failure a result of poor organisational culture? For example, acceptance of regular non-conformances,
OE12 profit prioritised over safety, resistance to change and improvement, poor safety leadership and promotion.
Did the absence or unavailability of the correct tools, equipment, machinery or PPE for use in the task or activity
lead to a mistake or failure? NOTE: If the correct tool(s), equipment, machinery or PPE was available for use by the
OE13 worker or operator but they chose not to use it, the ROOT CAUSES should be OE1 - Failure to adhere to PPIG /
taking shortcuts, and OE4 - PPE not worn or used incorrectly OR OE6 - Incorrect tool(s), equipment or machinery
handling, operation or selection.
Did poor, bright, radiated or reflected lighting, cold, hot or humid temperature, inadequate ventilation or excessive
noise in the work environment adversely affect the worker or operators’ ability to prepare for, or perform the task
OE14 or activity? Was the task conducted in adverse or severe weather conditions which exceeded the permissible
operating limits in relation to extreme cold / heat, wind, sea swell etc. OR was there a significant change in the
environmental conditions during the task or activity?

52 COMET ROOTMAP: MANAGEMENT
DID a lack of supervision OR inadequate task

planning, preparation or resourcing OR inadequate
NO management of, or accountability for PPIG OR poor
auditing, or failure to capture and / or implement
potential improvement opportunities contribute
to this COMET FACTOR?
NO Was the failure due to or related to the

supervisor not being present at the
jobsite / workplace?
M1 Supervisor absent
M2 Supervisor abstracted
M3 Supervisor missing
Was the failure due to or related to inadequate task

NO planning, preparation or resourcing?
Inadequate risk assessment / planning /

M4 preparation / supervision
Poor resourcing in terms of numbers/experience/skill

M5 set/competency assurance or fatigue management
M6 Poor scheduling of task or activity
Was the failure due to or related to inadequate

NO management of, or accountability for PPIG?
M7 PPIG does not exist or is inadequate or inaccurate
M8 Weak implementation of PPIG
M9 Weak enforcement of PPIG
M10 Weak individual or team accountability for PPIG
Was the failure due to or related to poor auditing,

the failure to capture and / or implement potential
NO
improvement opportunities?
M11 Missing or inadequate auditing or inspection process
Failure to implement or share best practice, through

M12 lessons learned, or from industry guidance or
regulatory requirement
M13 Ineffective capture of employee feedback
Poor implementation of previously identified

M14 preventive actions
go to EQUIPMENT

MANAGEMENT ROOT CAUSE DESCRIPTIONS 53
Did an error or failure occur as a result of a situation where the supervisor was completely absent from the
M1 workplace due to ill health, annual leave or other reason and the role had not been backfilled?
M2 Did an error or failure occur because a decision was taken by management to abstract the supervisor to perform
a different role elsewhere without replacing that area of responsibility?
Was the supervisor missing from the jobsite or workplace by personal choice, electing to be elsewhere during the
M3 immediate planning, preparation or performance of a particular task or at a critical point when supervision should
have been in place?
Did an error or failure occur as a result of inadequate task risk assessment / planning / preparation or because the
M4 supervisor or team leader at the site lacked the appropriate level of control, guidance, direction or leadership?
Was resourcing for the task an issue in terms of: insufficient work party numbers, experience, knowledge,
competency assurance or fatigue management? If an issue arose because management or a supervisor assigned
M5 personnel to a team with known pre-existing conflicts, or to a task whilst ill, suffering fatigue or any form of personal
upset or distress, then this root cause should be selected. Were incompetent behaviours by an individual or
individuals not identified and challenged or assessed through a formal competence assurance programme?
Did an error or failure occur as a result of poor task scheduling in respect of competing priorities, shift allocation,
M6 or as a result of undue pressure to complete the task within an improbable timeframe?
M7 Did an error or failure occur because the organisation failed to provide a PPIG, or because the PPIG was
inadequate or inaccurate?
Was an error or failure caused by the organisations’ weakness in ensuring implementation of the PPIG, resulting in
M8 those requiring it for the task or role to be undertaken, failing to receive it?
Did an error or a failure occur because the organisation failed to properly enforce the PPIG and were guilty of a
M9 lax approach to worker or operator adherence?
Did an error or failure arise as a result of an individual or team failing to accept or acknowledge their responsibility
M10 in terms of being held accountable for following or adhering to the PPIG? If management failed to convey to an
individual or team the onus of responsibility for PPIG adherence, also consider OE1 - Failure to adhere to PPIG /
taking shortcuts.
Did the organisation fail to identify previous shortfalls, or not have in place an effective and robust internal
M11 inspection and auditing regime?
Did the organisation fail to identify or implement acknowledged best practice or lessons learned? Such learnings
M12 or best practice could be internal lessons learned, generic recommended advice or guidance from industry leaders
or regulators.
Was there a shortfall in the organisations’ ability to capture or acknowledge employee feedback because no effective
M13 mechanism was in place to gather such opinion, or the existing method to do so does not work, resulting in missed
improvement opportunity? NOTE: also consider C6 - No written PPIG for the task or activity.
Was an error or failure allowed to recur because previously recommended specific preventive actions were not
M14 carried through and closed out? NOTE: If the organisation either dismissed or delayed these suggested actions then
this root cause is appropriate.

54 COMET ROOTMAP: EQUIPMENT
NO DID an equipment related issue contribute

Was the failure due to or related to flaws in the

NO equipments: design, manufacture or fabrication,
procurement, storage, handling or transportation,
installation or commissioning/quality assurance
E1 Flawed design
E2 Design not to specification
E3 Flawed manufacturing
E4 Flawed fabrication
E5 Flawed procurement
E6 Flawed storage/preservation
E7 Flawed transportation or handling
E8 Flawed installation
E9 Flawed commissioning/quality assurance process
Was the failure due to or related to equipment

maintenance, management, modification or an
NO inability to determine the cause of equipment
failures?
Non-existent or inadequate maintenance or

E10 inspection regime
Not maintained or inspected in accordance with an

E11 approved maintenance or inspection regime
Authorised modification or change of use not risk

E12 assessed or change managed
E13 Unauthorised or flawed modification of equipment
Unknown, undetermined or unmerited

E14 equipment failure
E15 Previous or repeat failure(s) not identified
Previous or repeat failure(s)

E16 identified but not addressed
go to TRAINING

EQUIPMENT ROOT CAUSE DESCRIPTIONS 55
E1 Did the equipment failure occur as a result of a flaw in the original design, specification or review process?
E2 Did the equipment failure occur as a direct result of non-adherence to the design specification?
Did the equipment failure occur as a result of errors within the manufacturing process?
E3 NOTE: This root cause does not relate to design issues or failure to adhere to the design specification or data.
Was the equipment failure a result of errors within the fabrication process?
E4 NOTE: For this root cause think well manufactured but poorly assembled flat pack items.
Did an equipment failure occur as a result of a flaw in its procurement, or that of a specific part, OR was
E5 there a failure in the wider procurement process?
Was poor or inadequate storage, for example in an unsuitable location or adverse atmospheric conditions, the
E6 cause of damage or corrosion that led to the equipment failure?
Was failure of the equipment the result of mishandling, dropping or by striking the equipment or component part
against another item of equipment, an object or a structure? OR Was the equipment failure the result of damage
E7 inflicted by incorrect, improper or careless transportation for example during a crane lift from a vehicle to the
workshop floor or jobsite?
Did equipment or component part fail as a result of an error in its installation or assembly, or the installation and
E8 assembly not being conducted as per the manufacturer’s recommendations or in accordance with any work permit,
guidance or instruction?
Did an equipment failure occur as a result of it not being commissioned or quality-assured prior to sign off for
E9 operational use? This includes final testing phase.
Was equipment failure the result of the organisation not compiling, establishing and / or implementing a suitable
E10 predictive or preventive maintenance or inspection regime? NOTE: This root cause does not relate to a failure to
adhere to a proper regime – see E11 below.
If a predictive or preventive maintenance or inspection regime existed, was equipment failure the result of a
E11 conscious deviation from the required maintenance regime or the taking of a shortcut in the process? NOTE: If this
is the case also consider ROOT CAUSES OE1 - Failure to adhere to PPIG / taking shortcuts, and M9 – Weak
enforcement of PPIG.
Did an equipment failure occur when modification or change of use was authorised but not suitably risk assessed or
E12 without due cognisance to the organisations’ documented ‘management of change process’? NOTE: Also consider
ROOT CAUSES M8 - Weak implementation of PPIG, or M9 - Weak enforcement of PPIG.
Was the equipment failure a result of its modification without authority or consent OR the use of wrong or
E13 unsuitable components or parts?
E14 Did the equipment fail and the cause remained unknown or was not deemed worthy of a full technical investigation?
Was there no method to detect, identify or record previous similar failures in the equipment or components?
E15 NOTE: This root cause applies if the organisation failed to have in place a suitable mechanism for capturing repeat
equipment failure. If this is the case, consider ROOT CAUSE M7 – PPIG does not exist or is inadequate or inaccurate.
Were previous failures identified in the specific equipment, machine or components or in similar equipment
elsewhere but not addressed or implemented through a robust preventive action programme? NOTE: This root
E16 cause applies if the organisation failed to have in place a suitable mechanism for capturing equipment failure. If this
is the case, consider ROOT CAUSE M7 – PPIG does not exist or is inadequate or inaccurate. Also consider ROOT
CAUSE M14 – Poor implementation of previously identified preventive actions.

56 COMET ROOTMAP: TRAINING
NO Did a training issue contribute to this

COMET FACTOR?
NO Was the failure due to or related to an absence

of training for the task, role or activity?
T1 No training provided
T2 Training requirement not identified
T3 Training not attended
Was the failure due to or related to

NO the management or quality of training?
T4 Inappropriate training provided
T5 Quality / standard of training inadequate
T6 Training not readily available
T7 No continuous competence assurance
T8 Training certification or accreditation lapsed
The analysis of this CF is complete.

Now take the next CF through the
Rootmaps.

TRAINING ROOT CAUSE DESCRIPTIONS 57
T1 Did a conscious organisational decision not to provide the individual with the requisite or specific training to
perform the task, role or activity lead to an error or a failure?
T2 Did the organisation fail to identify the need for specific training to equip the worker or operator with the
necessary skills for a task, role or activity?
Did an error or a failure occur because the worker or operator failed to attend planned or required training?
T3 NOTE: If the organisation condoned or failed to identify this missed training consider the ROOT CAUSE M9 - Weak
enforcement of PPIG.
Did the provision of the wrong training for the task, role or activity lead to an error or a failure? NOTE: If the
T4 organisation was party to this wrong training then consider the ROOT CAUSE M7 – PPIG does not exist or is
inadequate or inaccurate.
Was the training provided to the worker or operator sub-standard and as such, did not adequately equip them with
T5 the necessary skills to perform task, role or activity? NOTE: Consider also the ROOT CAUSE M11 - Missing or
inadequate auditing or inspection process.
Did an error or failure occur because there was no training readily available to be sourced for a particular task,
T6 role or activity?
Was there a lack of or insufficient competence assurance, for example a failure to identify the need for refresher
T7 training, to ensure ongoing ability to perform a task, role or activity competently.
Was there a lapse in certification or accreditation of a particular qualification or skill? NOTE: To select this ROOT
CAUSE it is not enough merely to show that the certification had lapsed. This does not necessarily mean that the
T8 worker or operators’ ability to perform a task or role is diminished. There must be evidence that the lapse in
certification directly contributed to an error or failure. If there is no evidence of this link, then it would be commented
or observed upon in the investigation report.

58 ROOT CAUSE GRID
You will now have collated all COMET FACTORS and ROOT CAUSES on your ROOT CAUSE Grid.
Remember that the number of COMET FACTORS in any incident investigation is indeterminable at
the outset. Likewise the number of ROOT CAUSES emanating from the COMET FACTORS cannot be
pre-determined.
Use the ROOT CAUSE Grid below during the training scenario.
ROOT CAUSE(S)
CF2
COMET FACTOR
CF3
CF4
CF5

ACTION

PREVENTIVE ACTION 59
OBJECTIVE
The final phase of the COMET process is ultimately the most important phase as effective, well implemented
Preventive Actions will deliver the change necessary to drive organisational improvement and hopefully
prevent repeat incidents. There is no point in conducting an Investigation and Root Cause Analysis if it
leads to nothing!
It is important that every ROOT CAUSE identified is addressed by a PREVENTIVE ACTION, however one
PREVENTIVE ACTION may be capable of addressing more than one ROOT CAUSE.
Where possible look for opportunities to create a single preventive action that can deal with or eliminate
multiple root causes. This makes the process more efficient and productive.
SMARTER Making it SMARTER Further Guidance

Specific What will we do and when? Detail what we are trying to achieve with this action.
Why is this different to what we do now?
Avoid flowery language. Designated person should
be aware that the action has been assigned to them,
but always assume they are not and write the action
as if they are reading it for the first time.
Measurable Can the action be measured Ensure the wording used will deliver resolution. ‘Sent
quantitatively? email’ is not a suitable closure. The designated
person must demonstrate that it is fully resolved.
Accountable Is the person responsible for It is important that one particular named individual is
implementation clearly defined and accountable to ensure consistency in implementation
aware of expectation? across the site/organisation and that they have the
necessary support and backing to achieve it.
Reasonable / Relevant Is it the optimum solution to gain a ‘Blue Sky’ actions must be avoided. Will the action
return on the investment (cost, time realistically solve or contribute to solving the issue? If
etc) required? not and it is simply ‘nice to do’, then it is not a
SMARTER action. Are there any assumptions we are
making with this action.
Timely Considering consequence of failure, is Dates should be realistic and agreed before actions
the due date reasonable – and assigned. Consider other workload and the priority
achievable? placed on the actions overall.
Effective Does the action contribute to the The close out should consider how to ensure the
elimination (or at least mitigate solution remains effective i.e. could a new action be
against) any recurrence? required if the issue persists? How will the proposed
action be sustainable and meet the test of time?
Reviewed Has an independent reviewer checked Certain actions may need more senior visibility,
the action has been effective, does it particularly if a failure to address the issue could
continue to be so and are there any have a major cost impact. This may be approval of
negative consequences as a result? the close out or periodic check-ins to confirm action
progress.

60 PREVENTIVE ACTION
EFFECTIVENESS
Some preventive actions are more effective than others:

Strong
Physical Controls
designed to separate
the Hazard from the
Target eg re-engineering
Strong Working Practices

Effectiveness eg Good Procedures, Workplace
Layout, Safety Culture
Human Behaviour
eg Discipline, Supervision, re-trap
Weak
Minimal Maximum
Preventive Action Effort
There are four categories of action plans to be considered prior to implementation ranging from
Category 1 and 2 actions are suitable for an immediate, short term solution, however for permanent or
lasting solutions there requires to be Category 3 or 4 actions. NOTE: BE CAREFUL THAT TEMPORARY
SOLUTIONS DON’T BECOME PERMANENT SOLUTIONS.
Timely close out of each preventive action plan coupled with a review of their effectiveness is critical to
long-term success.
Category 1 Category 2
Immediate, Advisory, Well Intentioned One Time Use, Immediate, Reactive
• Giving advice to an individual or group • Alerting people to unknown hazards
• An action not related to preventing the event • Informing people of additional technical information
• Financial punishment or rewards • Holding a Toolbox Talk
• Reminding personnel of points already known • Replace a missing piece of equipment
• Requesting further investigations or studies • Repair a defective piece of equipment
• Review a permit, procedure, work instruction, risk assessment • Implement additional safety signage or warning
• Implementing disciplinary procedures to an individual after • Modify a Risk Assessment or Toolbox Talk
the event • Assign an additional step to a task in immediate response to
• Planning to plan is not a plan incident as a counter measure
• A preventive action that does not follow the SMARTER technique • Re-train/educate an individual or team
Category 3 Category 4
One Time Use, Proactive, Local Specific Multiple Use, Multiple Areas, Organisational
• Train individuals/teams with new skills • Implement formal modifications to corporate policies and
• Modify location specific training requirements processes
• Implement a ‘one time use’ mechanical, electrical design • Embed changes and new specifications in to future procurement
modification • Modify training requirements and relevant job descriptions
• Employ person(s) to assist in short-term projects or assignments using competence assurance system
• Modify and embed changes to pre task hazard identification
• Implement disciplinary procedures for an ‘unsafe act with no
process
consequences’
• Implement investigation findings future audit process
• Implement a new piece of equipment, tool, system • Implement changes to formal process
• Implement formal modifications to work instructions and • Implement changes to routine work instructions and task
procedures procedures

PREVENTIVE ACTION 61
BEWARE OF THE ‘RE’ TRAP
There is little point in conducting a thorough investigation and identifying accurate root causes if the
preventive actions put in place are weak and ineffective. Falling into the ‘re’ trap is a common shortfall
when developing actions and the following are some examples:
Training
re-training
Discipline
remind, reinforce, reprimand
Policies & Procedures

review
The exceptions are RE-WRITE, RE-DESIGN and RE-ENGINEER
ROOT CAUSE PREVENTIVE ACTION ROOT CAUSE PREVENTIVE ACTION

62 COMMUNICATION ROOT CAUSES & PREVENTIVE ACTION PROMPTS
WHAT ARE PREVENTIVE ACTION PROMPTS?
The quality of Preventive Actions will determine the success or otherwise of the investigation and
potentially your reputation.
To help the investigation team avoid predictable unimaginative and ultimately weak Preventive Actions
the COMET process has an inbuilt set of PREVENTIVE ACTION PROMPTS
Each of COMETS 62 identifiable ROOT CAUSES has its own individual set of 4 PREVENTIVE ACTION PROMPTS
built on the 1 – 4 short to long term effectiveness.

1) Understand the source of the confusion/complexity and modify the existing PPIG to eliminate the problem. Consider the writer' ability.
2) Communicate any modifications to the PPIG community.
3) Consider the possibility that other PPIG sources are similarly affected and conduct a sample evaluation.
4) Consider future PPIG audits for effectiveness and ease of user understanding.

1) Understand the source of the inaccuracy and modify the existing PPIG to eliminate the problem. Communicate any amendments to the user
community.
2) Involve end users in the update process.
3) Consider the possibility that other PPIG sources are similarly affected and conduct a sample evaluation exercise.
4) Consider future PPIG audits for technical accuracy.

1) Ensure that the outdated PPIG is withdrawn and replaced with correct revision Record the change.
2) Make a localised supervisory assessment of resultant potential confusion/hazards caused by the error and remedy with an interim flash message until
new PPIG released.
3) Consider evaluation of all PPIG across the site and potentially across the wider organisation to assess if other outdated PPIG exists.
4) Identify and evaluate the systemic process for PPIG revision and ensure it meets the Management of Change requirements. Amend if necessary.
C4 PPIG incomplete
1) Understand where gaps in the relevant PPIG exist and remedy same.
2) Consider the need for an interim flash message to address the shortfall until the existing PPIG is amended.
3) Consider wider evaluation of PPIG across the site and potentially organisation to assess if other incomplete PPIG exists.
4) Ensure updated PPIG is communicated across the organisation and included in future PPIG audit programmes.
C5 PPIG difficult to access by users

1) Use whatever means available at a localised level to immediately ensure the availability of the PPIG to the user community.
2) Consult the supervisory community at a local level and troubleshoot means of improving PPIG access.
3) Consider wider evaluation of PPIG access across the site and potentially organisation to assess if other PPIG affected.
4) If suspected to be systemic ensure PPIG user access is included in future PPIG audit programmes.

COMMUNICATION ROOT CAUSES & PREVENTIVE ACTION PROMPTS 63

1) Consider an immediate `hold` on this task both locally and organisationally until PPIG is compiled and communicated. This will be dictated by
performing a Hazard Assessment.
2) Develop written PPIG in accordance with the task and communicate same locally and organisationally.
3) Perform an evaluation of similar tasks to assess if there are similar gaps.
4) Ensure scrutiny for potential gaps in written PPIG is included in future PPIG audit programmes.
C7 PPIG misunderstood due to cultural barriers, language difficulties or the use of jargon or acronyms
1) Rectify misunderstanding at a local supervisory level and ensure relevant PPIG community fully understand.
2) Evaluate means of performing briefings/toolbox talks/hand overs/communication of PPIG to eliminate use of jargon and overcome cultural barriers.
3) Consider an employee feedback campaign to assess the scope of this miscommunication issues.
4) Remedy communication difficulties at a systemic level based on feedback and build learning into future PPIG audit programmes.
C8 PPIG failed due to adverse environmental conditions such as noise / interference / interruption / weather or other form of distraction
2) Evaluate means of performing briefings/toolbox talks/hand overs/communication of PPIG to eliminate difficulties associated with adverse conditions.
3) Consider a wider employee feedback campaign to assess the scope of this miscommunication problem.
4) Remedy communication difficulties at a systemic level based on feedback and build learning into future PPIG audit programmes.
C9 PPIG failed due to faulty physical communication system

2) Consider a temporary replacement communications system at a localised level or an alternative means of communicating important information.
3) Troubleshoot the communications equipment failure to identify if this is a localised problem or a systemic issue.
4) Ensure communications equipment attracts the importance it deserves within the scope of the critical safety equipment maintenance regime.
C10 PPIG failed due to missing, or absence of, or poor / insufficient verbal briefing / handover for a task or activity, or during a shift change
2) Consider whether the communication deficiency is due to a training requirement for the individual(s) involved and is such training available? If not
consider this need.
3) Consider the need for an enhanced/more robust means of ensuring understanding of briefings/ shift handover at local and organisational wide
briefings/ shift handover.
4) Remedy briefing/shift handover communication challenges at a systemic level and build learning into future PPIG audit programmes.

64 OPERATING ENVIRONMENT ROOT CAUSES & PREVENTIVE ACTION PROMPTS

1) Before considering Preventive Action(s) for non-adherence to PPIG, ascertain if this was an isolated breach or become widespread common practice.
2) If the failure to adhere to PPIG / shortcut was an isolated conscious breach, consider human factors analysis to establish why it took place. If the
breach was malicious, consideration should be given to progressive discipline procedure.
3) If the failure to adhere to PPIG / shortcut was more commonplace then this suggests a failure by management to exercise effective control and this
needs to be addressed.
4) Ensure Preventive Action(s) are effectively communicated to the workforce and robustly built into supervisory and audit programmes.

1) Before considering Preventive Action(s) it is essential to ascertain if this was an isolated breach or become widespread common practice.
2) In any instance of carelessness, consider human factors analysis to establish why it took place. If the breach was malicious, consideration should be
given to progressive discipline procedure.
3) For instances of horseplay or media device distraction, consideration should be given to progressive discipline procedure. If issues are commonplace,
then this suggests a failure by management to exercise effective control and this needs to be addressed.
4) It is vital the Preventive Action(s) be effectively communicated to the workforce and robustly built into supervisory and audit programmes.
OE3 Poor team dynamics, or a lack of situational awareness leading to a hazard induced condition
1) Consider the reasons for any breakdown in team working. Are the relationships within the team conducive with effective working? A re-allocation of
team members may be required.
2) In any instance of loss of situational awareness, consider human factors analysis to establish why it took place.
3) Instil this best practice as a matter of routine into task related PPIG - pre task briefings/toolbox talks/JSAs etc. Consider imaginative means of
improving workforce behaviour through human factor workshops/ poster campaigns / employee idea schemes etc.
4) Ensure there are pro-active means organisationally of capturing best industry practice and cascading across the organisation as per 3 above.
2) If the failure to wear PPE was an isolated conscious breach, consider human factors analysis to establish why it took place. If the breach was
malicious, consideration should be given to progressive discipline procedure.
3) If the failure to wear PPE was more commonplace then this suggests a failure by management to exercise effective control and this needs to be
addressed.
4) Consider imaginative means of improving workforce PPE behaviour through Human Factor Workshops/poster campaigns/Employee idea schemes etc.
OE5 Improper/inadequate isolation or overriding of safety systems or controls
2) If the failure was an isolated conscious breach, consider human factors analysis to establish why it took place. If the breach was malicious,
consideration should be given to progressive discipline procedure.
3) If the failure was more commonplace then this suggests a failure by management to exercise effective control and this needs to be addressed.
4) Consider imaginative means of improving workforce behaviour through Human Factor Workshops/poster campaigns/Employee idea schemes etc.
OE6 Incorrect tool(s), equipment or machinery handling, operation or selection

2) If the failure was an isolated conscious breach, consider human factors analysis to establish why it took place. If the breach was malicious,
consideration should be given to progressive discipline procedure.
3) If the failure was more commonplace then this suggests a failure by management to exercise effective control and this needs to be addressed.
4) Consider imaginative means of improving workforce behaviour through Human Factor Workshops/poster campaigns/Employee idea schemes etc.
OE7 Substance abuse

1) Ensure that the immediate physical and mental requirements of the affected personnel are met and the company duty of care discharged. Involve
Human Resources.
2) Perform a security review of the particular circumstances to identify and mitigate the potential for further breaches involving access to banned
substances.
3) Have an awareness of the potential for reputational damage through media awareness. Involve Corporate Communications.
4) Incorporate any learnings in an organisational communications and audit strategy on the risks of substance abuse in the workplace.

OPERATING ENVIRONMENT ROOT CAUSES & PREVENTIVE ACTION PROMPTS 65
OE8 Change in the setup or layout affecting equipment operating environment

1) Perform a localised Human Factors evaluation of the worksite to ascertain if continued operations are safe. Involve a `fresh set of eyes` in this process.
2) Evaluate the localised management of change PPIG to assess if it requires improvement or if not, why it was not followed?
3) Consider an organisational awareness and communication campaign to the workforce reinforcing the risks of unplanned changes in the workplace.
4) Ensure that adherence to MOC PPIG organisationally is included in future audit and supervisory programmes.
OE9 Confusing/inadequate controls/displays/labels/ alarms/instrumentation or signage

1) Consider temporary localised measures to eliminate the issue causing concern however if this is not possible consider a `stop`.
2) Consider an external or independent Human Factors evaluation of the worksite to generate improvement actions. Consider if other sites may be
affected.
3) Consider an organisational employee feedback campaign to engage the workforce in what `good` looks like with regard to simplified controls/displays
etc.
4) If systemic issues exist there may need to be evaluation of an engineering design solution e to permanently address the problem.

1) Assign a local site-based supervisor with the task of performing an immediate worksite evaluation to assess the extent of the problem and seek a
solution.
2) If the obstruction cannot be removed or re-designed consider all means of communicating to the workforce the hazard through signage/briefings.
affected.
4) If systemic issues are identified there may need to be consideration of an engineering design evaluation to permanently address the problem.
OE11 Obstructed or restricted workplace/hazard inducing conditions

1) Assign a local site-based supervisor with the task of performing an immediate worksite evaluation to assess the extent of the problem and seek a
solution.
2) If the obstruction cannot be removed or re-designed consider all means of communicating to the workforce the hazard through signage/briefings.
affected.
4) If systemic issues are identified there may need to be consideration of an engineering design evaluation to permanently address the problem.

1) Carry out an assessment of how employees view the current culture. This will only be successful if carried out in a way that allows employees to be
completely open an honest. Therefore, responses should be captured anonymously.
2) Assess the current method of capturing employee feedback in relation to any issues or concerns that may emerge across all areas of the organisation.
Consider encouraging further engagement in this area.
3) Ensure that the organisations values and goals are clearly defined at a strategic level, and also integrated into everyday activities at an operational
level.
4) Develop an improvement programme that relies on employees being able to openly contribute in areas where they feel the organisation could do
better. This must be promoted and encouraged from the highest level of management.
OE13 Correct tools, equipment, PPE or machinery not available

1) Assign a local site-based supervisor with the task of performing an immediate worksite evaluation to assess the extent of the unavailability and why.
2) In the short term supplement the local site with the shortfall or if unable to do so consider a `stop work` position or re-evaluation activity.
3) This is possibly an isolated issue but if not, it could be a safety culture indicator. Consider a series of snap site inspections and build into audit
programme.
4) Ensure that correct tool, equipment or machinery availability organisationally and its importance in safe working practices is included in future audit and
supervisory programmes.
OE14 Adverse lighting/temperature/ventilation/noise environment/severe weather conditions

1) Assign a local site-based supervisor with the task of performing an immediate worksite evaluation as to potential shortfalls. Could the job have been
deferred and if so why wasn`t it?
2) Evaluate the adequacy and enforcement of the PPIG relative to the risks of exposure to the workforce of unsatisfactory environmental conditions.
affected.
4) If systemic issues are identified consider the value of an imaginative organisational education campaign highlighting good practice in respect of
working or indeed not working in challenging environmental conditions.

66 MANAGEMENT ROOT CAUSES & PREVENTIVE ACTION PROMPTS
1) Consider the immediate need at a localised level to supplement the workforce with a suitable supervisor. Ascertain why it was considered acceptable to
dispense with the need to backfill the role.
2) Evaluate the local PPIG in terms of task scheduling and planning to ensure any future absence of a supervisor is addressed and not simply managed
without action.
3) Consider a workforce supervisory engagement campaign to reinforce the importance of the role and seek feedback as to the organisational extent of
this problem.
4) If this is believed to be a systemic issue there may be a need to reinforce appropriate PPIG communication/ enforcement and build in same to future
audit programmes.
1) Consider the immediate need at a localised level to supplement the workforce with a suitable supervisor. Ascertain why it was considered acceptable to
dispense with the need to backfill the role.
2) Evaluate the local PPIG in terms of task scheduling and planning to ensure the abstraction of a supervisor from a particular role or task is properly risk
assessed and managed.
3) Consider a workforce supervisory engagement campaign to reinforce the importance of the role and seek feedback as to the organisational extent of
this problem.
audit programmes.
1) Consider the immediate need to reinstate supervision at the actual jobsite.
2) If the decision by the particular supervisor to leave the worksite without managing his absence is unjustified there may be a need to consider
disciplinary action.
3) Consider a workforce supervisory engagement campaign to reinforce the importance of the role and seek feedback as to any organisational learnings
that exist.
audit programmes
.
M4 Inadequate risk assessment / planning / preparation / supervision

1) Consider a localised evaluation of the effectiveness of task risk assessment/planning, including learnings from previous incidents to ascertain if there is
a weakness or gaps.
2) If this particular issue is isolated and simply relates to a supervisor not doing their job and is not indicative of wider culture consideration should be
given to progressive disciplinary action.
3) Consider a workforce supervisory engagement campaign to reinforce the importance of pre task planning and seek feedback as to any organisational
learnings there may be.
audit programmes.
M5 Poor resourcing in terms of numbers / experience / skill set / competency assurance or fatigue management
a weakness or gaps.
audit programmes.

a weakness or gaps.
audit programmes.

a weakness or gaps.
audit programmes. Copyright © 2020 STC Global Ltd. All Rights Reserved.
MANAGEMENT ROOT CAUSES & PREVENTIVE ACTION PROMPTS 67

) Ensure the affected PPIG is immediately implemented and communicated at a localised level to prevent or reduce the likelihood of recurrence.
2) Identify what the barriers were that resulted in the weak implementation of the PPIG and address this through a site based supervisory workshop.
3) Consider a workforce supervisory engagement campaign to reinforce the importance of effective PPIG and seek feedback as to any organisational
learnings or improvement ideas.
audit programmes.

1) Ensure before taking action that there is evidence either locally at an asset or organisationally that management are culturally lax or unable to ensure
PPIG adherence.
2) Beware of falling into the trap of blaming those involved for not following PPIG. This is a widespread issue and will require organisational effort to
resolve.
3) Consider a workforce supervisory engagement campaign to reinforce the importance of PPIG adherence and seek feedback as to any organisational
audit programmes.

1) Ensure accountability for PPIG adherence is well understood. Did those involved in the task understand fully they were accountable for PPIG
compliance?
2) Consider a localised evaluation of pre task planning/ briefing as this is a natural point where accountability is reinforced. Good toolbox talks will
demand an accountability sign off.
3) Consider a workforce supervisory engagement campaign to reinforce the importance of PPIG accountability and seek feedback as to any organisation-
al learnings or improvement ideas.
4) If this is believed to be a systemic issue there may be a need to reinforce appropriate PPIG accountability and build in same to future audit
programmes.

1) You need to understand why the audit program failed. Are audits too infrequent, lacking depth, lacking meaningful engagement? Are the auditors
adequately trained?
2) Evaluate both localised and organisational audit regimes to ensure they are fit for purpose and meet both organisational and regulatory demands.
3) Audits are generally unpopular! Consider a workforce engagement campaign to reinforce the importance of effective audit regimes in improving safe
working conditions.
4) If this is believed to be a systemic issue there may be a need to recruit the services of an independent audit consultancy to deliver robust and objective
recommendations.
M12 Failure to implement or share best practice, through lessons learned, or from industry guidance or regulatory requirement
1) Consider a localised evaluation of how best industry practice/lessons learned from previous incidents are captured and shared. Also consider how this
could be improved.
2) Key to success is a workforce engagement and communication program which is active and topical. Dreary circulations will not succeed however
imaginative campaigns will.
3) Consider a workforce supervisory engagement campaign to reinforce the importance of sharing best practice. Seek feedback as to any organisational
4) If this is believed to be a systemic issue there is an organisational requirement to ensure that as a minimum external regulatory guidance is being
captured and cascaded.
M13 Ineffective capture of employee feedback

1) Consider performing a worker feedback evaluation at both localised and organisational level. If schemes exist are they working effectively from ground
level to management?
2) Test the effectiveness of any existing scheme by tracking spoof suggestions from entry point to end point. Was the suggestion taken seriously and was
the employee updated?
3) Consider a workforce supervisory engagement campaign to reinforce the importance of employee feedback. Seek feedback as to any organisational
4) If this is believed to be a systemic issue there may be a need to reinforce appropriate PPIG relative to employee feedback and build same into future
audit programmes.
M14 Poor implementation of previously identified preventive actions

1) Immediate action must be to implement the previously identified preventive action to avoid another or second repeat failure. If this cannot be done,
consider stopping the job and re-evaluating.
2) Organisations are entitled to take business decisions NOT to implement recommended preventive actions however this has to be defendable. Is
decision making robustly captured?
3) Evaluate the means by which the organisation tracks the close out of recommended preventive actions from investigations. PA log jams can often lead
to good actions being `lost`.
4) If this is believed to be a systemic issue there is an organisational requirement to ensure that Senior Management is provided with a means of tracking
and scrutiny. Copyright © 2020 STC Global Ltd. All Rights Reserved.
68 EQUIPMENT ROOT CAUSES & PREVENTIVE ACTION PROMPTS
E1 Flawed design
1) Ensure that immediate or short-term remedial action has been taken to replace, repair or isolate the adversely affected equipment.
2) Communicate the design flaw across your organisation and initiate an inspection process of similar equipment types.
3) Consider initiating an industry wide alert of your findings and possibly the regulator if the equipment is safety critical.
4) Evaluate the organisational PPIG to identify improvement measures to prevent future design flaw issues. Consider involving legal if design was third
party vendor.
E2 Design not to specification

2) Communicate the design specification flaw across your organisation and initiate an inspection process of similar equipment.
3) If the fabrication was by an external vendor consider initiating an industry wide alert of your findings and possibly the regulator.
4) Evaluate the organisational PPIG to identify improvement measures to prevent future design specification issues. Consider involving Legal.
2) Communicate the manufacturing flaw across your organisation and initiate an inspection process of similar equipment.
3) If the manufacturing was by an external vendor consider initiating an industry wide alert of your findings and possibly the regulator.
4) Evaluate the organisational PPIG to identify improvement measures to prevent future manufacturing issues. Consider involving Legal.
1) Ensure that immediate or short-term remedial action has been taken to replace, repair or isolate the affected adversely equipment.
2) Communicate the fabrication flaw across your organisation and initiate an inspection process of similar equipment.
3) If the fabrication was by an external vendor consider initiating an industry wide alert of your findings and possibly the regulator.
4) Evaluate the organisational PPIG to identify improvement measures to prevent future fabrication issues. Consider involving Legal.
2) Communicate the procurement issue across your organisation and initiate an inspection process of similarly procured equipment.
3) It is important to identify if this is a localised procurement issue where perhaps site purchasing by-passed the MOC process or is it more widespread?
4) Evaluate the organisational PPIG to identify improvement measures to prevent future equipment procurement issues.
1) Ensure that immediate or short-term remedial action has been taken to address the flawed storage issue.
2) Communicate the storage flaw across your organisation and initiate an inspection process of equipment similarly stored.
3) It is important to identify if this is a localised storage issue or more widespread across the organisation If widespread consider environmental
conditions, i.e. dust, heat, humidity, ice etc.
4) Evaluate the organisational PPIG to identify improvement measures to prevent future equipment storage issues. consider environmental conditions, i.e.
dust, heat, humidity, ice etc.

2) Communicate the transportation/handling issue across your organisation to activate measures to avoid repeat incidents.
3) It is important to identify if this is a localised transportation/ handling issue or more widespread across the organisation.
4) Evaluate the organisational PPIG to identify improvement measures to prevent future equipment transportation/handling issues.
1) Ensure that immediate or short-term remedial action has been taken to replace, repair or isolate the affected equipment.
2) Communicate the flawed installation issue across your organisation to activate measures to avoid repeat incidents.
3) It is important to identify if this is a localised installation issue or more widespread across the organisation.
4) Evaluate the organisational PPIG to identify improvement measures to prevent future equipment issues relating to flawed installation.

EQUIPMENT ROOT CAUSES & PREVENTIVE ACTION PROMPTS 69

2) Communicate the flawed commissioning/QA issue across your organisation to activate measures to avoid repeat incidents.
3) It is important to identify if this is a localised commissioning? QA issue or more widespread across the organisation.
4) Evaluate the organisational PPIG to identify improvement measures to prevent future equipment commissioning issues.
E10 Non-existent or inadequate maintenance or inspection regime

2) This will not be an isolated issue. Depending on the scale of the issue consider an organisational assessment of the problem.
3) Consider a workforce supervisory engagement feedback campaign to understand why required maintenance regimes do not exist or are failing.
4) If this is believed to be a systemic issue there may be a need to reinforce appropriate maintenance PPIG and build in same to future audit programmes.
E11 Not maintained or inspected in accordance with an approved maintenance or inspection regime
2) This will not be an isolated issue. Depending on the scale of the issue consider an organisational assessment of the problem.
3) Consider a workforce supervisory engagement feedback campaign to understand why required maintenance regimes are not being followed.
4) If this is believed to be a systemic issue there may be a need to reinforce appropriate maintenance PPIG and build in same to future audit programmes.
E12 Authorised modification or change of use not risk assessed or change managed
2) Is this a localised issue and if so, what is driving this behaviour? Where possible avoid discipline options and seek positive engagement to understand
why.
3) Unauthorised modification of equipment is often a symptom of a `can do` mentality but is dangerous. Consider creative education campaign to deter.
4) If this is a systemic issue there may be a need to reinforce appropriate MOC PPIG adherence and build in same to future audit programmes.
E13 Unauthorised or flawed modification of equipment

1) Ensure that immediate or short-term remedial action has been taken to replace, repair or isolate the adversely affected equipment or components.
2) Is this a localised issue and if so, what is driving this behaviour? Where possible avoid discipline options and seek positive engagement to understand
why.
3) Unauthorised modification of equipment is often a symptom of a `can do` mentality but is dangerous. Consider creative education campaign to deter.
4) If this is a systemic issue there may be a need to reinforce appropriate MOC PPIG adherence and build in same to future audit programmes.
E14 Unknown, undetermined or unmerited equipment failure

2) If it is deemed that the equipment failure is of such minor worth that identifying the cause is not a valuable exercise ensure this decision is defendable.
3) Consider capturing minor equipment failure data centrally such that the organisation is able to trend same to potentially identify common failure modes.
4) Ensure the list of àcceptable equipment failures` or the £ value by which this is determined is reviewed annually at an organisational level.
E15 Previous or repeat failure(s) not identified

1) Ensure that immediate or short-term remedial action has been taken to replace, repair or isolate any adversely affected equipment.
2) Repeat failure(s) indicate potential issues with the quality of previous investigations and improvement programs. Consider an independent investigation.
3) Consider a workshop evaluation of dip sampled previous equipment failure(s) and track the end to end investigation / preventive action process for issues.
4) If this is a systemic issue there may be a need to evaluate appropriate failure investigation PPIG for effectiveness and build in same to future audit
programmes.
E16 Previous or repeat failure(s) identified but not addressed

1) Ensure that immediate or short-term remedial action has been taken to replace, repair or isolate any adversely affected equipment.
2) Organisations are entitled to take business decisions NOT to implement recommended preventive actions however this has to be defendable. Is
decision making robustly captured?
3) Review the means by which the organisation tracks the close out of recommended preventive actions from investigations. PA log jams can often lead to
good actions being `lost`.
4) If this is believed to be a systemic issue there is an organisational requirement to ensure that Senior Management is provided with a means of tracking
and scrutiny. Copyright © 2020 STC Global Ltd. All Rights Reserved.
70 TRAINING ROOT CAUSES & PREVENTIVE ACTION PROMPTS
1) In the short term ensure the organisation provides the individual(s) with the required training or re-designate the task to trained personnel.
2) If this specific training doesn’t exist within the organisation management should action the development of same internally or scope a suitable external
provider.
3) Consider a localised evaluation of supervisory pre job planning procedures to understand why untrained personnel were assigned to a task.
4) If this is believed to be a systemic issue there may be a need to evaluate PPIG relative to training/competence assurance and build same into future
audit programmes.
T2 Training requirement not identified

2) If this specific training doesn’t exist within the organisation develop same internally or scope a suitable external provider.
3) Consider a localised evaluation of supervisory pre job planning procedures to understand why the requirement for task training was not identified.
4) If this is believed to be a systemic issue there may be a need to evaluate PPIG relative to the organisational training matrix and build same into future
audit programmes.

2) Consider a localised evaluation of supervisory pre job planning procedures to understand why the requirement for task training was not identified.
3) Evaluate the organisational PPIG in relation to the robustness of the end to end training identification, notification and attendance for improvement
opportunities.
4) If this is believed to be a systemic issue there may be a need to evaluate PPIG relative to organisational training assurance and build same into future
audit programmes.

2) If the correct training doesn’t exist within the organisation develop same internally or scope a suitable external provider.
3) Consider a localised evaluation of training provision PPIG to understand why wrong training was provided or why the correct training was not identified
as essential.
4) If this is believed to be a systemic issue there may be a need to evaluate PPIG relative to organisational training assurance and build same into future
audit programmes.

2) Consider a localised evaluation of supervisory pre job planning procedures to understand what aspect(s) of the training failed.
3) Consider suspending further training programmes involving the same training provider until a proper QA assessment can be made.
4) Consider an evaluation of organisational training provision to assure that existing training provision is fit for purpose and also to eliminate reasons why
this failure occurred.

2) Consider a localised evaluation of supervisory pre job planning procedures to ascertain if they adequately address training and competence.
3) Consider an organisational evaluation of training provision to understand why there was a timescale conflict between training required and training
available.
4) If this is believed to be a systemic issue there may be a need to evaluation PPIG relative to organisational training assurance and build same into
future audit programmes.

1) In the short term there may be a need for the organisation to provide the individual(s) with the required refresher training.
2) Consider an organisational evaluation of training provision to understand why there was a failure to address the need for refresher or continuous
improvement training.
3) Consider creative means of reminding personnel of upcoming training needs...e.g. friendly personalised reminder notes on monthly payslips.
4) If this is believed to be a systemic issue there may be a need to evaluate PPIG relative to refresher training assurance and build same into future audit
programmes.
T8 Training certification or accreditation lapsed

1) Confirm that the lapse in certification or training records actually contributed to the incident. Skills or operational ability don’t simply diminish on a given
re-certification date.
2) Consider a localised evaluation of supervisory pre job planning procedures to ensure training certification is addressed.
3) Consider an organisational evaluation of training provision to understand why there was a failure to address the need for a reliable recertification program.
4) If this is believed to be a systemic issue there may be a need to evaluate PPIG relative to recertification assurance and build same into future audit
programmes. Note: if deliberate falsification is uncovered this needs to be addressed from a discipline perspective.
INVESTIGATION
PROMPT CARD TAB
PROMPT CARDS

SCENE MANAGEMENT 71
Your first priority is to make the area safe, treat any injuries and minimise damage to the
environment and site. Next focus on securing the scene and any relevant equipment
for examination. Remember that once the scene has been released and returned to
normal, the evidence may be lost forever, so it is better to err on the side of caution
and initially preserve everything that may have a bearing on the investigation at a
later stage.
1. Have you ensured that it is safe to proceed with the

examination of the scene?
2. Have you established and recorded any changes to the

scene post incident?
3. Have you considered housekeeping/obstructions/confined

space as potential factors?
4. Have you considered the potential impact of environmental

conditions - internal and external?
5. Have you adequately recorded the scene using

photographs/videos/sketches/plans/diagrams?
6. Have all items of physical evidence been retained, packaged

and securely stored?
7. Have you considered requesting specialist examination of

the scene or items recovered?

72 EQUIPMENT
Ensure you have full understanding and inventory of all of the types of equipment
relevant to the incident. Ensure that all equipment is properly identified and recorded.
Take physical possession of equipment that requires to be examined. If it is not possible
to remove that equipment consider the need to quarantine it until an on site
examination can be carried out.
Personal Protection Equipment (PPE)

1. Have you confirmed what PPE ought to have been in use?
2. Have you identified what PPE was actually used?
3. Was the PPE fit for purpose, well maintained and fully operable?
4. Were the operators trained and competent in the use of PPE?
Tools
5. Have you confirmed what tools ought to have been in use?
6. Have you identified what tools were actually used?
7. Were all tools used correct for the task?
8. Were the tools fit for purpose, well maintained and operable?
9. Were the operators trained and competent in the use of the tools?
Machinery
10. Was the machinery maintained as per the maintenance regime?
11. Have any unauthorised changes been made to the machinery?
12. Were the operators trained and competent to use the machinery?
13. Was the machinery set up properly and operated correctly?
14. Has the machinery been examined for any faults/failures?
15. Were there any changes in its use - what’s different this time?

PERSONNEL PROFILES 73
A variety of information regarding the members of staff involved in the planning,

supervision and performance of the activity surrounding the incident will be of
relevance to the investigation to test the capability, capacity and competence of key
personnel in the respective roles they fulfilled. Enlist the assistance of a nominated
HR single point of contact to gain access to the information required and ensure
that access complies with company policy. This information also provides valuable
context to opinions expressed by witnesses surrounding what took place and the
actions of other people involved.
1. Have you established who was involved in the planning,

supervision and performance of the task?
2. Have you confirmed that they were trained, competent and

authorised to perform their role?
3. Have you considered their previous experience and

familiarity with the role?
4. Have you checked if they were involved in previous incidents?
5. Did they have any work restrictions due to impairment or

physical capability?
6. Were there any related performance/conduct issues?
7. Have you ensured that Human Factors have been fully

considered?

74 DOCUMENTS
Documents come in a variety of formats ranging from hard copy, electronic data and
digital files. Ensure that adequate systems are put in place for their secure retention
and review. Retain documents and catalogue them using a reference system. Store
them securely. The catalogue should be reviewed at regular stages to assess the
validity of each item in relation to the investigation.
1. Have you secured all documentation relevant to the

investigation?
a) Regulatory/Advisory - HSE/OSHA Regulations and

Guidance/Industry Standards etc.
b) Management - Company Policy/Golden Rules/

Standard Operating Procedures
c) Activity Specific - Risk Assessment/Method Statements/

Guidance/Instructions
d) Equipment - Maintenance History/Operating Procedures/

Inspection Records etc.
e) Personnel Profiles - Employment Records/Training

Records/Work Records/Personal Records
2. Have the documents been fully reviewed to establish

relevance, authenticity and provenance?
3. Have the documents been properly catalogued and filed for

future reference?

WITNESS INTERVIEWS 75
The PRISM model provides the structure for witness interviews. Focus on planning
and preparation. Categorise your witnesses and learn what you can about them in
advance. Use the Interview Planning Sheet to assist preparation and to set out
your key interview objectives. Practice good questioning and listening techniques.
1. Who?
• What is their employment history/industry experience?
• How long have they been with the company? In what roles?
• What relevant qualifications/accreditation do they have?
• What is their relationship to other witnesses?
• Do they have any performance issues or history of non-
compliance?
2. Why?
• Why do they feature in the investigation?
• Why do you need to interview them?
3. What?
• What are the key objectives of this interview?
• What do you already know about this witness’s involvement?
• What information do you hope to confirm?
• What gaps in your knowledge do you hope to fill?
4. Where?
Conduct an interview in an area where the witness will feel
comfortable and with minimal distractions and interruptions.
5. When?
Before commencing an interview make sure you plan and
prepare so that you have sufficient knowledge of any technical
aspects of the incident.
6. How?
Use the PRISM interview model and productive questioning and
listening techniques.
* See also Appendix B and C

APPENDICES

APPENDIX A - HUMAN FACTORS GUIDE 76
JOB FACTORS
HF1 Were any signs, signals, or other visual indicators alerting the team to an issue missed, overlooked or ignored
HF2 Did the illogical layout or design of the worksite, controls or equipment adversely affect the task being performed?
HF3 Was the task performed in a difficult or challenging workplace environment eg adverse weather or hazardous conditions?
HF4 Did poorly maintained equipment or tools or a lack of access to the correct tools or equipment play a role in the incident?
HF5 Was the briefing or instruction for the task adequate?
HF6 Was there a procedure for the task and if so was it followed as required?
HF7 Was communication amongst the work team adequate or were there issues that should have been addressed?
HF8 Was there any disagreement within the team as to how the task should have been planned or performed?
HF9 Were any particularly routine, were shortcuts taken or was the task performed in a hurry?
HF10 Was the task overly complex, difficult or particularly unusual?
HF11 Was the performance of the task affected by disruptions or interruptions?
INDIVIDUAL FACTORS
Was any member of the team distracted by personal issues or suffering a physical incapacity that may have impacted
HF12 on the task performance?
HF13 Was any member of the team fatigued, bored, distracted or overwhelmed?
HF14 Was any member of the team suffering from high levels of stress or were there issues of low morale in the workplace?
HF15 Did any member of the team require additional skills to perform the task?
ORGANISATIONAL FACTORS
HF16 Was any member of the team unclear on their role in the task or team member responsibilities?
Was the sufficient supervision and leadership for the task and were rules around the following of policies and
HF17 procedures properly enforced?
Were there sufficient resources available to perform the task and was there a sufficient emphasis on prioritising safety
HF18
vs production?
HF19 Has such an incident or similar taken place within the organisation previously?
HF20 Did team members feel the safety culture in the organisation empowered to stop the job if they felt it was unsafe?
20 QUESTIONS SHOULD BE EXPLORED WITH WITNESSES DURING EVERY

INVESTIGATION AND SHOULD BE USED TO HELP FORM INTERVIEWS.

77 APPENDIX B - INTERVIEW PLANNING
WITNESS NAME
ROLE DEPARTMENT
INTERVIEWER 1 INTERVIEWER 2
OTHERS PRESENT
TIME/DATE LOCATION
EXPERIENCE
ROLE IN
INCIDENT
KEY TOPICS
1 4
2 5
3 6

APPENDIX C - INTERVIEW RECORD 78
WITNESS NAME
ROLE DEPARTMENT
EMAIL TELEPHONE
ADDRESS
INTERVIEWER 1 INTERVIEWER 2
OTHERS PRESENT
TIME/DATE LOCATION
STATES:

79 APPENDIX D - BARRIER EVALUATION
STEP 3 - IDENTIFY THE BARRIERS STEP 4 - IDENTIFY WHAT

STEP 1 - IDENTIFY HAZARD STEP 2 - IDENTIFY TARGET THAT SHOULD HAVE BEEN IN BARRIERS WERE EFFECTIVE,
PLACE FAILED AND MISSING
effective
failed
missing

APPENDIX E - CHANGE EVALUATION 80
ENVIRONMENT MANAGEMENT REGIME

Consistently high quality SID:Grids. Regularly producing SID:Grids that
Generally producing good quality
Accurate timeline with solid do not meet acceptable standards. 81
SID:Grids. Accurate timeline with
supporting data. Extent of timeline Lacking quantity and quality of
solid and proportionate amount of
SID:Grid composition – and supporting data timeline and data required. <50% of
A supporting data. > 75% of SID-
Event/Data ratio commensurate with incident. SID:Grids meet acceptable best
Grids meet acceptable best
<10% of SID:Grids required practice standards.
practice standards.
improvement.
Regularly utilising the BE/CE Occasionally utilising the BE/CE

Rarely utilising the BE/CE feature
feature and x-mapping same onto feature however missing
Utilisation of Barrier / and missing frequent opportunities
B the SID:Grid to enhance COMET opportunities where the technique
to make use of this feature
Change Evaluations Factor identification. could have been useful.
Consistently identifying CFs that Generally identifying CFs that reflect

Regularly identifying COMET
reflect the context of the incident the context of the incident with
Factors that do not meet the
with supporting evidence and meet supporting evidence and meet the
Quality and number of definition of a COMET Factor.
C the definition of a COMET Factor. definition of a COMET Factor.
COMET Factors
> 50% of investigations out-with
< 10% investigations are out-with > 25% of investigations are out-with
2 to 7 COMET Factors.
2 to 7 COMET Factors. 2 to 7 COMET Factors.
Consistently identifying RCs that Generally identifying RCs that

Regularly identifying Root Causes that
reflect the context and supporting reflect the context and supporting
do not meet the definition of the
APPENDIX F - BEST PRACTICE
evidence of the incident COMET evidence of the incident COMET

Quality and number of Factors. incident COMET Factors.
D Factors.
Root Causes
> 50% of investigations are out-with
< 10% investigations are out-with < 25% investigations are out-with
2 to 10 Root Causes.
2 to 10 Root Causes. 2 to 10 Root Causes.
Consistently identifying Preventive Generally identifying Preventive

Regularly identifying Preventive
Actions that accurately reflect the Actions that reflect the Root
Actions that fail to meet the best
Quality and number of Root Causes and meet the best Causes and meet the best practice
practice SMARTER criteria.
E practice SMARTER criteria. SMARTER criteria.
Preventive Actions > 50% of actions fall out with best
< 10% of actions fall out with best < 25% of actions fall out with best
practice parameters.
practice parameters. practice parameters.
BEST PRACTICE
PARAMETERS
Measures to indicate optimal use of the COMET tool.

APPENDIX G - COMET SCALABILITY AND BEST PRACTICE 82
COMET investigations and Root Cause Analysis for incidents/unplanned events is scalable depending
on the nature of the event and its category of actual/potential severity. Please refer to your
organisations Risk Matrix guidance for further information.
Please see below some best practice and guidance for conducting different levels of COMET investigations.
SID:Grid
In a lower level event investigation, the investigation timeline may only require limited events (up to 12)
and pertinent supporting data only. However, a higher level event investigation may require a far more
extensive timeline (unlimited) with substantial supporting data. This will be driven by circumstances and
the volume of information required to be considered.
COMET Factors
A lower level event investigation which has limited data will likely have fewer COMET Factors however
this will always be driven by known facts and data. A higher level event investigation will typically
contain more. For guidance, with any investigation, if you have identified fewer than 2 or more than
7 COMET Factors, this should trigger a review as anything outside these parameters would not be
considered best practice. That said, there may always be the special or unique case where the number
of COMET Factors does sit out with these guidelines.
Root Causes
Identified COMET Factors will lead to specific root causes. Each COMET Factor will typically lead to multiple
root causes. For guidance, if you have identified fewer than 2 or more than 10 root causes per COMET
Factor, this should trigger a review. Again, root cause analysis will always be driven by the data gathered
during the investigation.
Actions
Each Root Cause must be addressed with at least one Preventive Action. Always adhere to SMARTER
principles and the Preventive Action Prompts when creating actions.

83 APPENDIX H - COMET PROCESS FLOW
SID: GRID
BARRIER & CHANGE

EVALUATION
COMET FACTOR LATENT FACTOR
OPPORTUNITY FOR
ROOT CAUSES ORGANISATIONAL
IMPROVEMENTS
PREVENTIVE ACTIONS

APPENDIX H - COMET INVESTIGATION PROCESS GUIDE 84
COMET COMET Lite

SID:Grid; the number of events and data points is SID:Grid; the number of events on the timeline
unlimited. A full COMET SID:Grid could take a should be limited to 10 or less.
number of days, weeks or potentially months to
complete depending on the circumstances of the Similarly data points should be limited to the
pertinent information only.
incident.
STEP 1 The building of a COMET Lite SID:Grid should take
The DISCOVER phase of completing the SID:Grid
will include coverage of all investigation areas, SID:GRID approximately 15 minutes.
namely Scene Management, Equipment, CONSIDER USE OF SID:GRID DESKPAD

Documents, Human Factors, Witnesses and
Interviewing.
MINS
DAYS
30
In a COMET Lite investigation it is only necessary
Completing both a Barrier and Change Evaluation
to complete a single barrier evaluation focusing
is an ESSENTIAL step in a full COMET Investigation on the most obvious incident hazard. Failed or
to identify or validate COMET FACTORS. This will missing barriers must be cross referred with the
typically take place towards the end of the SID:Grid.
investigation or DISCOVERY phase.
Change evaluation is also completed focusing on
The findings from both evaluations i.e failed or any adverse change.
missing barriers and/or adverse changes that
contributed to the incident must be reflected and
STEP 2 This should take 15 minutes.
cross referred with the SID:Grid. BARRIER & CONSIDER USE OF ‘Easy as ABC’ EVALUATION
CHANGE DESKPAD
EVALUATION
A SID:Grid sweep of all event and data points A SID:Grid sweep of all event and data points will
will take place to identify COMET Factors using the take place to identify COMET Factors using the CF
CF definition test. definition test.
Pay particular attention to failed and missing

Pay particular attention to failed and missing
barriers uncovered during Barrier Evaluation as
barriers uncovered during Barrier Evaluation and these may well be COMET Factors.
adverse changes identified during Change
Evaluation as these may well be COMET Factors. Aim to identify between 2 and a maximum of 4
STEP 3 COMET Factors only.
COMET
Identifying COMET Factors during a COMET Lite
FACTOR should take approximately 10 minutes.
IDENTIFICATION
HOURS
MINS
20
Each identified COMET Factor must be taken Each identified COMET Factor must be taken
through the 5 COMET Root Maps consecutively. through the 5 abbreviated COMET Root Maps
Each COMET Factor must be considered using only consecutively. Each COMET Factor must be
the information pertaining to that individual considered using only the information pertaining
to that individual COMET Factor. Root Causes
COMET Factor.
identified must be recorded using the Root Cause
Grid. This step is only complete once all COMET
Root Causes identified must be recorded using the Factors have been considered through the 5
Root Cause Grid. This step is only complete once abbreviated Root Maps. Aim to select between
all COMET Factors have been taken through the 5 STEP 4 2 and a maximum of 4 root causes per COMET
Root Maps.
ROOT MAPS actor. Root Maps should take 10 minutes.
CONSIDER USE OF ROOT MAP DESKPAD
Each identified Root Cause must be addressed with Each identified Root Cause must be addressed
at least one Preventive Action plan, however the with a preventive action plan. Refer to COMET’s
number of actions is unlimited until the solution is SMARTER guidance and Preventive Action
effective. Prompts when developing actions.
HOURS
MINS
Aim for between 1 and a maximum of 2

10
Refer to COMET’s SMARTER guidance and preventive actions per root cause. Where
Preventive Action Prompts when developing possible develop a single action to deal with
actions.
STEP 5 multiple root causes.
PREVENTIVE This step should take approximately 10 minutes.
ACTIONS
NOTE: The COMET Lite timings are guidelines and not
completely prescriptive. However if an investigation is
realistically going to take considerably longer than 60
minutes a full COMET investigation is required.

COMET LITE

COMET LITE BREAKDOWN 85

86 COMET LITE OVERVIEW
COMET LITE has been specifically designed to complement its parent COMET RCA toolset and is deployed
when it meets the following criteria:
• Meets our organisational incident / unplanned event categorisation matrix for low potential risk incidents.
• The SID:Grid will not contain more than 10 events on the timeline.
• The end to end investigation will realistically and foreseeably take approximately 60 minutes.
The COMET LITE tools enable a quick (approximately 60 minute) investigation outcome whilst still generating
meaningful and accurate root causes and subsequent preventive actions.
If your COMET LITE investigation & analysis generates results that change the incident’s Categorisation to
a more serious level then you should immediately upscale to the use of the full COMET.
MINOR SERIOUS MA JOR CATASTROPHIC

first-aid; unable to conduct hospitalisation
HEALTH & SAFETY short term normal work for and significant fatality
work restriction several days medical treatment
small release significant major

with no release requiring pollution pollution with
ENVIRONMENT
lasting impact local clean-up and damage contamination
no publicity limited considerable

or external publicity & local / regional national
REPUTATION
impact local interest publicity publicity
moderate significant major costs

none, or slight damage / loss with damage / loss and profit
ASSET & FINANCIAL
damage / loss some disruption & disruption impact
RARE
not expected to n
ever happen again tio
ga
sti
ve
UNLIKELY In
1
EL
RECURRENCE
not expected in
V n
foreseeable future LE tio
stiga
POSSIBLE ve
may occur again In
from time to time EL2
L EV n
tio
LIKELY st iga
e
will reoccur but
Inv
not regularly
L 3
VE
CERTAIN LE
will happen
again soon
CONSEQUENCES

DISCOVER 87
WHAT HAPPENED?
STEP 1 - BUILD THE SID:GRID
The first thing you need to do is establish your incident timeline. To do this you should use your
COMET SID:Grid (Significant Investigation Data Grid).
The SID:Grid is designed to assist the investigator to understand what took place in the leading up to,
during and following the incident. To achieve this it is necessary to gather all the relevant and significant
information related to the incident and use it to develop a chronological sequence of events.
NOTE: The incident timeline should not exceed 10 events.
The SID:Grid is an excellent tool to visually display this information in an easy to comprehend and
organised manner. In a COMET LITE the construction of a SID:Grid is a straightforward process using
the abbreviated SID:Grid pad (insert) or onto the electronic version.

88 DISCOVER
STEP 2 - PART 1 - PERFORM AN ABBREVIATED BARRIER EVALUATION
What BARRIERS were missing / failed?
It is important to consider what BARRIERS were either missing or failed. The function of a BARRIER is to
prevent an undesirable action from taking place or protect the system and its people from the
consequences if it does occur. A COMET LITE BE should only focus on the main incident / unplanned event
hazard.
Consider that these barriers, both active and passive, which may exist in various forms:
PHYSICAL: cages, containment, PPE, valves, walls

FUNCTIONAL: braking systems, interlocks, passwords
SYMBOLIC: alarms, colour/shape control coding, warning signs etc
NON-PHYSICAL: policies/procedures/instruction/guidance (PPIG), processes, supervision, training
…and plot your outcomes on your SID:Grid. By identifying these failed and missing barriers and determining
their effectiveness in relation to the incident you will potentially identify COMET Factors.
STEP 2 - PART 2 - PERFORM AN ABBREVIATED CHANGE EVALUATION
What changed or was done differently?
Next you need to consider what has changed, plotting any adverse change on your SID:Grid.
Consider each of the following categories:
PEOPLE – someone new / someone missing?

TIME – short cut, scheduling, pressure?
EQUIPMENT – missing, new, modified?
ENVIRONMENT – weather, lighting, noise, workplace set-up?
MANAGEMENT – policy, procedure, performance?
REGIME – maintenance, inspection, training?
PREVENTIVE BARRIERS PROTECTIVE BARRIERS

Adverse change which directly contributed to the incident Physical/engineering – valves, isolation, guarding etc
Pre job planning – PTW, JSA, toolbox talks etc

Physical/engineering – spill containment, fire doors etc
Effective and well maintained shutdown & alarm safety systems
or made matters worse will be COMET FACTORS.

Effective shutdown and intervention systems Effective emergency response/contingency plans
Adequate task scheduling and resourcing Adequate emergency response awareness and exercise
Effective and well enforced PPIG Adequate zone management – drop zones/barrier control etc
Effective and active supervision Effective and well enforced PPIG
Adequate sinage, alarms and warning Effective and active supervision
Adequate and well maintained tools and equipment Adequate sinage, alarms and warning
Adequate inspection and audit regime Adequate and well maintained PPE
Make use of your COMET LITE ‘Easy as ABC’ guide as Competent and trained personnel
Other:
Competent and trained personnel
Other:
pictured on the right.

EFFECTIVE MISSING FAILED NOT APPLICABLE EFFECTIVE MISSING FAILED NOT APPLICABLE
INCIDENT
PRE INCIDENT POST INCIDENT
Easy as ABC - Abbreviated Barrier & Change Evaluation

Use the Preventive and Protective Barrier Evaluation templates to identify
MISSING? SHORTCUT? MISSING?
barriers that were effective, missing or failed. Missing or Failed Barriers will
NEW? SCHEDULING? DIFFERENT? potentially be COMET factors whilst Effective Barriers will help support the
MODIFIED? PRESSURE? TEAM DYNAMICS? identification of robust Preventive Actions
DEFECTIVE? DELAYS? RESOURCE NUMBERS?
Use the Change evaluation template to identify adverse change(s) in the
WEATHER? POLICY? MAINTENANCE? task pre planning and performance that contributed to the incident or
made matters worse. Again these will potentially be COMET factors and
LIGHTING/NOISE ETC? PROCEDURE? INSPECTION?
may reflect what was uncovered in the Barrier Evaluation.
HOUSEKEEPING? PRODUCTIVITY? TRAINING?
WORKPLACE SET UP? PERFORMANCE? SUPERVISION? Failed and Missing barriers and adverse change(s) should
ENVIRONMENT MANAGEMENT REGIME be highlighted on the SID:Grid

ANALYSE 89
Your SID:Grid will now contain all the information you need to conduct your COMET Lite analysis.
STEP 3 - IDENTIFICATION OF COMET FACTORS
A COMET FACTOR IS DEFINED AS...
“HUMAN ERROR,
ORGANISATIONAL SHORTFALL
OR SYSTEM/EQUIPMENT/PROCESS FAILURE...
...THAT DIRECTLY CONTRIBUTED TO THE INCIDENT

OR MADE MATTERS WORSE”.
OBJECTIVE
The first stage of the Analysis phase is the identification of what are known as COMET Factors. Once
identified the second stage of the analysis process is to take each COMET Factor through the 5 COMET
root maps to determine the ROOT CAUSES relating to the incident under investigation.

Environment
IDENTIFYING COMET FACTORS
COMET Factors can be identified in a number of different ways however they have to meet the above
definition. Mistakes or failures that exist on the SID:Grid but did not directly contribute to the incident
or its consequences are NOT COMET Factors. They may however be what is known as Latent Factors
covered later in this section.
BARRIER & CHANGE EVALUATION FINDINGS
Important attention should be paid to the outcomes of Barrier and Change Evaluations. In most
instances, failed or missing barriers will by default meet the COMET Factor definition as will identified
adverse change(s). This emphasises the importance of Barrier and Change Evaluations as investigation
tools to either help identify or validate COMET Factors on the SID:Grid. However, the COMET Factor
definition should always be adhered to. Evaluation findings which DO NOT meet the definition will
become Latent Factors.
NOTE: In a COMET LITE analysis it is important in terms of proportionality to aim for the
identification of between 2 and 4 COMET Factors.
90 ANALYSE
STEP 4 - IDENTIFICATION OF ROOT CAUSES
Take each specific COMET FACTOR identified on your SID:Grid in turn and apply it to the set of
5 COMET LITE abbreviated ROOT Maps. A positive answer to any gateway question will direct you to a
group of ROOT CAUSES from which you can select those which are relevant.
NOTE: In a COMET LITE analysis it is important in terms of proportionality to aim for the
identification of between 2 and 4 ROOT Causes per COMET Factor.

Environment
DID failure of written or verbal communication of

NO Policies, Procedures, Instruction or Guidance (PPIG),
or an absence of PPIG, contribute to this COMET
FACTOR?
NO Was the failure due to or related to written

communication?
C4 PPIG incomplete
C5 PPIG difficult to access by users
Was the failure due to or related to verbal

NO communication?
PPIG misunderstood due to cultural barriers,

C7 language difficulties or the use of jargon or acronyms
PPIG failed due to adverse environmental conditions
C8 such as noise / interference / interruption / weather
or other form of distraction
PPIG failed due to faulty physical
C9 communication system
PPIG failed due to missing, or absence of, or poor /
C10 insufficient verbal briefing / handover for a task or
activity, or during a shift change
go to OPERATING ENVIRONMENT

ANALYSE 91

Environment
DID failure to adhere to PPIG, undesirable human

behaviour or poor organisational culture OR the
NO improper use / availability of tools, equipment OR
the lay out of the workspace, contribute to this
COMET FACTOR?
NO Was the failure due to or related to PPIG

adherence or undesirable human behaviour?
Poor team dynamics, or a lack of situational

OE3 awareness leading to a hazard induced condition
Improper / inadequate isolation or overriding of

OE5 safety systems or controls
Incorrect tool(s), equipment or machinery handling,

OE6 operation or selection
OE7 Substance Abuse
Was the failure due to or related to the improper

use or availability of tools, equipment or machinery,
NO the set up / lay out of the workspace or the existing
culture in the workplace?
Change in the setup or layout affecting

OE8 equipment operating environment
Confusing / inadequate controls / displays / labels /

OE9 alarms / instrumentation or signage
Obstructed or restricted workplace / hazard

OE11 inducing conditions
Correct tools, equipment, PPE or machinery

OE13 not available
Working in adverse lighting/temperature/ventilation/

OE14 noise environment/severe weather conditions
go to MANAGEMENT

92 ANALYSE

Environment
DID a lack of supervision OR inadequate task

planning, preparation or resourcing OR inadequate
NO management of, or accountability for PPIG OR poor
auditing, or failure to capture and / or implement
potential improvement opportunities contribute
NO Was the failure due to or related to the

supervisor not being present at the
jobsite / workplace?
Was the failure due to or related to inadequate task

NO planning, preparation or resourcing?
Inadequate risk assessment / planning /

M4 preparation / supervision
Poor resourcing in terms of numbers/experience/skill

M5 set/competency assurance or fatigue management
Was the failure due to or related to inadequate

NO management of, or accountability for PPIG?
Was the failure due to or related to poor auditing,

the failure to capture and / or implement potential
NO
improvement opportunities?
Failure to implement or share best practice, through

M12 lessons learned, or from industry guidance or
regulatory requirement
M13 Ineffective capture of employee feedback
Poor implementation of previously identified

M14 preventive actions
go to EQUIPMENT

ANALYSE 93

Environment
NO DID an equipment related issue contribute

Was the failure due to or related to flaws in the

NO equipments: design, manufacture or fabrication,
procurement, storage, handling or transportation,
installation or commissioning/quality assurance
E1 Flawed design
E2 Design not to specification
Was the failure due to or related to equipment

maintenance, management, modification or an
NO inability to determine the cause of equipment
failures?
Non-existent or inadequate maintenance or

E10 inspection regime
Not maintained or inspected in accordance with an

E11 approved maintenance or inspection regime
Authorised modification or change of use not risk

E12 assessed or change managed
E13 Unauthorised or flawed modification of equipment
Unknown, undetermined or unmerited

E14 equipment failure
E15 Previous or repeat failure(s) not identified
Previous or repeat failure(s)

E16 identified but not addressed
go to TRAINING

94 ANALYSE

Environment
NO Did a training issue contribute to this

COMET FACTOR?
NO Was the failure due to or related to an absence

of training for the task, role or activity?
T2 Training requirement not identified
Was the failure due to or related to

NO the management or quality of training?
T8 Training certification or accreditation lapsed
The analysis of this CF is complete.

Now take the next CF through the
Rootmaps.

ACTION 95
STEP 5 - CREATION AND IMPLEMENTATION OF PREVENTIVE ACTIONS
The investigation process is not complete until the lessons learned have been implemented and
measures put in place to prevent or at least minimise the chance of recurrence.
It is important that every ROOT CAUSE identified is addressed by a PREVENTIVE ACTION, however one
PREVENTIVE ACTION may be capable of addressing more than one ROOT CAUSE.
NOTE: In a COMET LITE analysis it is important in terms of proportionality to aim for the creation
of between 1 and 2 effective PREVENTIVE ACTIONS per ROOT Cause. Always look for
opportunities to deal with multiple ROOT Causes with a single PREVENTIVE ACTION.
PREVENTIVE ACTION is:
• The most important stage in the process
• Your opportunity as an investigator to make a lasting difference
All PREVENTIVE ACTIONS should be based on SMARTER principles.
Take each specific ROOT CAUSE from the ROOT CAUSE Grid and use the PREVENTIVE ACTION table to
devise actions which would be effective at addressing the ROOT CAUSE.
Is the action:
- SPECIFIC: what will we do and when?

- MEASURABLE: can it be measured quantitatively?
- ACCOUNTABLE: clearly define & inform named person
- REASONABLE/RELEVANT: is it justifiable & proportionate
- TIMELY: is the timescale achievable and reasonable?
- EFFECTIVE: ensure the solution has been effective
- REVIEWED: review for unintended consequences

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DISCOVER ANALYSE ACTION

“A COMET FACTOR IS A HUMAN ERROR, ORGANIZATIONAL SHORTFALL OR

“THE CAUSE OF A PROBLEM WHICH, IF ADDRESSED, WILL PREVENT OR

• COMET Factor identiﬁcation

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SCENE MANAGEMENT & EQUIPMENT 05

COMET ROOT MAPS 47

ROOT CAUSE GRID 58

PREVENTIVE ACTION PROMPTS 62

ADDITIONAL MATERIALS (SEE TABS)

INVESTIGATION PROMPT CARDS

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Copyright © 2020 STC Global Ltd. All Rights Reserved.

Building a SID:Grid is a simple four step process:

STEP 1 – IDENTIFY THE INCIDENT AND HIGHLIGHT IT IN RED

STEP 2 – OUTLINE THE SEQUENCE OF EVENTS ALONG THE TOP LINE

STEP 3 – ADD SUPPORTING DATA BELOW EACH EVENT

- Scene Management & Equipment - Witnesses

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STEP 4 – CONTINUALLY REVIEW FOR ANY GAPS

This is often the case in a lone worker incident.

SEQUENCE OF EVENTS PRE INCIDENT INCIDENT POST INCIDENT

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SAFE STABLE SECURE SURVEY

TOOLS MACHINERY PARTS, PPE

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RECORDING THE SCENE

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RECOVERY OF PHYSICAL EVIDENCE

ALWAYS REFER TO THE SCENE

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TOOLS MACHINERY PARTS, FITTINGS PPE

EQUIPMENT INVESTIGATION ROUTE

There is a natural sequence when

ALWAYS REFER TO THE

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• Has this happened before?

• Is there a failure history with similar equipment?

• Could this failure extend beyond the immediate asset?

• Has the equipment been modified since design?

• Has anything changed or been modified in the process where the

• If so, was there appropriate Management of Change (MOC)?

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• Was Planning / Preparation of the equipment operation adequate?

• Was the operator of the equipment competent?

• Was there adherence to standard operating procedures?

• Is there a maintenance regime in place?

• Is it fit for purpose?

• Has it been followed and recorded?

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• Was there sufficient pre job planning of the installation?

• Did this involve competent personnel?

• Was sufficient time scheduled for the installation?

• Is there unexplained damage/degradation to the equipment?

• Could poor storage be a factor? e.g. corrosion

• Could the transportation process be a factor? e.g. damage in transit

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• Does a Procurement Process exist?

• Has it been followed correctly?

• Are there any local/site deviations to the central

• Is the incident sufficiently serious to justify investigating any

• Can design data be accessed?