This is the first in a three-part series.
To see if your organization suffers from complacency when it comes to incident investigations, answer these three challenge questions:
1) What was the most recent significant change to your investigation protocol and when was it made?
2) When was the last time your organization undertook a formal evaluation of the effectiveness of your investigation process?
3) Do you periodically look outside your organization to understand what other best practice organizations are doing to make their investigation process work effectively for them?
If you can’t answer these challenges in an affirmative way, don’t feel alone — most organizations don’t score well on these issues.
Most organizations have a static investigation protocol — one that really hasn’t changed in years. If we don’t undertake a brutally honest assessment and don’t look outside our organization for how others are doing this, we remain in our comfortable cocoon, oblivious to the larger world around us.
In most organizations, investigations fail to deliver their potential value. But investigations fail at predictable points within the investigation process and fail in predictable ways. This allows an organization to make targeted interventions that quickly lead to substantial improvements.
The first failures
Most organizations have a document outlining their investigation process — an expectation from leadership on what is expected. Such a document needs to be a clear and direct statement of what the organization is committed to doing, written in the ‘say what we do, do what we say’ mode.
One common failure is a tendency to overpromise — for example, organizations will typically include a broad definition of an ‘accident’ followed by a commitment to investigate all accidents, but without the necessary resources at the local level to have any chance to deliver on that commitment.
Critical issues that should be addressed in your investigation procedure include the expected timeline for the investigation, team selection and training requirements for investigators.
Police often refer to the first 48 hours of an investigation as the critical period, as their studies show the chances for a successful resolution drop dramatically after that point. If you aren’t even starting your investigation until the 48-hour mark, you are setting your teams up to fail. Additionally, investigations need to be completed in a timely manner, as interest and focus on a particular incident will only last for a finite period.
Issues around team selection can be simply put as follows — the wrong team will rarely find the right answer. Your procedure should include guidance on team size, team dynamics and roles and accountabilities. It should also be recognized that not everyone is suited for investigation work. As humans we all have our own biases and a successful investigator needs to be able to put those aside.
The first necessary step to improving your investigation results is to take a fresh hard look at your policy/procedure documents and eliminate the errors and omissions.
Once a specific investigation is started, there are predictable areas where the process can go astray. Any investigation has three distinct phases: information gathering; analyzing evidence for cause factors; and reports and recommendations.
Information gathering
At the information-gathering phase, a common issue is the failure to differentiate betweeninformationandevidence.
At the early stages of the investigation, the team should be focused on the collection of all availableinformationwithout attempting to assess the veracity, relevance or importance of any individual bit.
Once the bulk of the information has been gathered, the team can apply specific techniques to make reasoned judgments on what bits of information ‘pass the test’ and become the factual foundation of the investigation. Premature judgments are usually made in accord with a person’s bias, and not with a defensible methodology.
To assure the completeness of the information being gathered, teams should focus on the four main sources of information available in nearly every investigation. Those four sources are the four Ps — thepartsinvolved, the people involved (both directly and indirectly), the physical position of the people and parts and any paper records (recognizing we are now moving toward an electronic world). Two of these four sources are usually handled very well — parts and paper.
Position information is the most susceptible to change over time. While it is essential to care for any injured personnel, the scene is being markedly changed. Capturing this information as soon as possible is critical. Nearly all failures with position information occur as a result of timing issues.
In most investigations, the people indirectly and directly involved are the single most valuable source of information. Yet our ability to extract that information in a timely, consistent and fair way is generally lacking. Here’s why:
Most safety pros recognize there is nothing in the typical educational curriculum that teaches this skill, and what they have “learned” about interviewing has come from trial and error and watching others — others who suffer from that same lack of training.
An interview is about your ability to extract information, it is not about what a person remembers. An individual who has witnessed a significant event will retain a vivid memory of that occurrence. An interview is a test of your ability to extract that information — never a test of their ability to remember.
Effective interviews require: 1) Expert instruction and supervised demonstration exercises in a solid, defensible methodology; 2) Adequate opportunities to practice these skills to keep them current; and 3) Discipline to use them when interviewing.
Next month: Part two in this three-part series examines analyzing evidence for cause factors and investigation reports and recommendations.
