The Systemic Occurrence Analysis Methodology is a comprehensive process for analysing data collected as part of a safety occurrence investigation, and for generating logical findings and recommendations.
SOAM is one of a number of accident investigation methodologies based on the Reason Model of organisational accidents. The purpose of a systemic occurrence analysis methodology is to broaden the focus of an investigation from human involvement to include analysis of the latent conditions deeper within the organisation that set the context for the event.
Such an approach is consistent with the tenets of Just Culture in which people are encouraged to provide full and open information about how incidents occurred, and are not penalised for errors. It should also be noted that a truly systemic approach is not simply a means of transferring responsibility for a safety occurrence from front-line employees to senior managers. A consistent philosophy must be applied, where the investigation process seeks to correct deficiencies wherever they may be found, without attempting to apportion blame.
Like other systemic analysis techniques, SOAM forces the investigation to go deeper than a factual report that simply answers basic questions such as “What happened, where and when?" First, data must be collected about the conditions that existed at the time of the occurrence which influenced the actions of the individuals involved. These in turn must be explained by asking what part the organisation played in creating these conditions, or allowing them to remain, thereby increasing the likelihood of a safety occurrence. SOAM thus supports the fundamental purpose of a safety investigation - to understand the factors which contributed to an occurrence and to prevent it from happening again.
Place of SOAM in the Investigation Process
The main focus of SOAM is on two key phases of the investigation process:
- Analysis of factors contributing to the occurrence, and
- Development of recommendations.
These activities are distinct from, but follow logically from:
- Factual information gathering, and
- Graphical reconstruction of the event sequence (e.g., using SOFIA).
In using SOAM, the preparation of a final chart of contributing factors and the development of recommendations are activities which are best conducted "manually" by the investigator(s), rather than with the aid of a software or database tool. However, the output of findings and recommendations produced using SOAM is suitable for subsequent uploading into a tool like SOFIA. This has the benefit of clearly separating the very distinct investigation activities of event reconstruction, causal analysis and preparation of recommendations.
Recommendations from a SOAM-based investigation will be directed towards remediation of contributing systemic factors and failed barriers, a process that is not dependent on an exhaustive analysis of underlying cognitive error mechanisms.