As HSE Practitioners, we've all been there. An incident occurs, and we are pressured to quickly discover what happened and how to prevent it from happening again. But in the rush to get answers, it's easy to fall into common traps that can derail even the most well-intentioned investigation.
Awareness of these pitfalls can help you avoid sabotaging your efforts to learn from incidents and improve safety performance. So, let's dive into the deadly sins of incident investigation and how you can avoid them:
Rushing In: It's a classic mistake to want to wrap things up quickly. But rushing your investigation is like building a house on sand. You must ensure you have a solid foundation that can't be washed away. Take the time to plan your data collection and analysis. Look at every relevant detail. A systematic approach will yield far more accurate and valuable findings.
Wanting Answers Now: Everyone understands you need answers quickly, even yesterday. However, complex incidents often have multiple causes. Patience is essential. Taking the time to investigate thoroughly will help you understand the root causes and prevent future occurrences.
Being a 'Lone Wolf': Incident investigation is a team sport. Different perspectives, diverse expertise, and active discussion are crucial for uncovering the truth. Avoid the temptation to go it alone and leverage all the team's knowledge and skills.
Looking to Blame: Blame is the enemy of learning. Focus on understanding the why behind the incident, not the who. If interviewees feel that you're looking to blame one of their colleagues unjustly, they might be less forthcoming with the information you need for a quality investigation. A just culture that encourages reporting and learning from mistakes is essential for continuous improvement.
Making Assumptions: We all see the world through our own lens, but assumptions can cloud our judgment and drive the investigation down the wrong path. Challenge your assumptions and encourage your team to do the same. Try to quantify all your 'assumptions' with at least two forms of evidence. Tools like Storyboard and Root Cause Analysis charts can help you see the bigger picture.
Dismissing the 'Naïve' Ideas: Sometimes, the most innovative solutions come from unexpected places. Don't dismiss seemingly simple or "naïve" ideas, especially from team members who have little experience in the incident being investigated. Fresh perspectives can unlock breakthroughs.
Being Egotistical: If you think, "I'm the boss, I know best," then it's a fast track to stifling open communication and effective investigation. Instead, adopt a coaching style that empowers your team to contribute their best, you should listen more than you talk, be transparent and not withhold information, and above all, be respectful - the investigation isn't about you; it's about helping the organization to learn lessons and prevent future incidents and harm.
Stopping Too Soon: Identifying the immediate cause is just the first step. You must stay curious and don't discard information too early. Keep asking, "Why?" be curious until you reach the root cause(s). If something doesn't feel right, question it and validate the evidence provided. This deeper understanding is vital for preventing similar incidents.
Not Seeing the Purpose: Incidents are rarely caused by a single factor. Embrace the concept of "mutual arising" – the interconnectedness of events, people, and systems. Your investigation should aim to uncover these complex relationships.
Treating Reporting as Investigating: Simply filling out a form is not an investigation. Use a robust investigation technique to gather reliable data and generate meaningful insights. Follow the process, don't make assumptions or skip steps just because you think you know what the results will be.
Effective incident investigation is a critical component of any robust safety management system. By avoiding these common traps, you can transform incidents from setbacks into opportunities for learning and improvement.
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