Safety Leadership: Event learning: Rethinking incident investigations

Editor’s Note: Achieving and sustaining an injury-free workplace demands strong leadership. In this monthly column, experts from global consulting firm DEKRA share their point of view on what leaders need to know to guide their organizations to safety excellence.

How happy are you with the value you gain from your incident investigations? Do you find that your investigations help you gain insight into the drivers of incidents and prevent future problems?

If the answer is no, there may be many reasons, including focusing on a single cause, pressure to produce results quickly, an emphasis on finding fault vs. learning, investigators with limited training and experience, and restrictive software reporting requirements.

We all know Albert Einstein’s definition of insanity is doing the same thing over and over again and expecting different results. Yet, we seem to continue to do this with incident investigations. Even though safety has come a long way over the past few decades, we need to rethink incident investigations.

What should a new paradigm look like?

An investigation should eliminate, reduce or control exposure to injury. Exposure is the vulnerability that occurs when people intersect with a hazard. This vulnerability surfaces for many reasons, and may go beyond standard hazard recognition that most organizations understand. Usually, picklists, terminology wars and opinionated discussions over the cause don’t result in a reduction of exposure because they lack context. Do corrective actions address the vulnerability? If they don’t, an investigation becomes nothing more than a paper exercise.

Most investigators don’t have human-performance knowledge, and most systems/tools don’t address human performance in a meaningful way – or they use outdated concepts. Until we accept that humans will make mistakes, understand the ways and reasons they make them, and have strategies to combat them, we’ll always be leaving exposure on the table. People simply work within the systems designed for them.

Even when good investigations are done, it’s rare that problems are studied at the system level to apply learning. If an investigation output (report) doesn’t elevate to a higher level for further action, you’re solving your problems one site – or business unit – at a time.

I recall a dinner I had with a client overseas a few years ago. He talked about how his region put together a team to solve one of their most pressing issues (they were successful).

However, during a later meeting at corporate headquarters, he learned that other business units and regions had solved the issue years ago. No one knew it because the company had no established process for organizational learning.

It’s long overdue that we repurpose the time we spend on investigations and leverage organizational learning. It’s time we stop arguing over root cause and start to better understand and eliminate, reduce or control exposure.

I want to acknowledge all the thoughtful and hard work that safety leaders at all levels do every day. By taking pride in that fact and working together, I have no doubt we’ll keep pushing the boulder up the hill. It’ll be exciting to watch our discipline evolve.

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