Analysis of events, accidents or near misses

An event analysis is a method that helps to determine

  • what happened
  • how it happened
  • why it happened
  • how to prevent recurrence by corrective measures
  • For that it is not only the event process that needs to be reconstructed, but also the causes (constributing factors) are to be determined, which causes the event, promotes the process, or influenced in the functional chain.

    Event analysis represents a relevant instrument of experience backflow within the organization / company.

    The consistent application of its systematic analysis methodology leads to avoiding incidents due to similar causes and contributes significantly to the continuous improvement process in the areas of human, technology and organization.

    BAUA Hollistic Event Analysis – Guide to identify fundamental causes of accidents in small and medium-sized enterprises

    Under the project number F2287 the following project was carried out by BAUA(Bundesanstalt für Arbeitsschutz und Arbeitsmedizin) in cooperation with TÜV Nord SysTec GmbH & Co. KG: Ermittlung grundlegender Ursachen von Unfällen, Ereignissen und Beinahe-Unfällen (Root-Cause-Analysis) zur Prävention in kleinen und mittleren Unternehmen.

    We too have contributed to the success of this project.

    As part of this project, the guide for event analysis was developed.

    SOL Method for in-depth event analysis

    The method SOL was developed from 1992 at the Technical University of Berlin (Becker et al., 1995).

    SOL is based on the "Swiss cheese model" of Reason (1990) and the socio-technical approach, which were merged into the socio-technical event development model. This postulates that accidents in industries with high risk potential arise due to the interplay directly and indirectly contributing factors from the subsystems individual, team, organization, organizational environment and technology as well as their interaction. Furthermore, it is believed that accidents always happens due to several contributing factors and to be seen as a sequence of individual events (Fahlbruch & Schöbel, 2011).

    There are many publications available e.g. IAEA TECDOC-1756 (2015).

    The SOL method was the first analysis method integrated into our software products SOL-VE and SOL-VE OEM in 2004.

    Today, SOL is used with SOL-VE OEM in German and Swiss nuclear technology.

    In 2013, a team of the originators of SOL as well as other scientists and practitioners has come together to adapt and optimize the method on the basis of the recognized change in requirements. The characteristic approach (separation of description of the event sequence and identification of the contributing factors) and the advantages of SOL (e.g. extensive sample collection for explaining the factor categories) were of course obtained.

    The new version SOL 3.0 was presented from 2014 to the SOL-VE OEM users and as well the specialist audience across all industries (= Human Factors experts in event analysis) and checked in several practical tests.

    © 2022 SOL-VE GmbH