Investigation – a Beginning and an End

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Where does an investigation start and where does it end? That’s a question that exercises us all at Kelvin TOP-SET, because we profess to be the investigation experts.

The start is possibly easier to identify than the end: the start begins with an incident or event that requires investigation. That event can be good or bad. There is no harm in investigating something that went right, to find out why it went right. So, it’s not all doom and gloom. It’s even possible to carry out a Root Cause Analysis on success. Why did no one die when the Airbus A320 ditched in the Hudson River with around 150 passengers and crew on board? Because of luck certainly, but many other things were well set for success: the design of the plane, the pilot’s skill and training, the evacuation procedures, the skills of the crew in organising the evacuation, the behaviour of the passengers, and many others involved in the rescue mission. All went well, and all survived – a remarkable event – but one that still requires investigating for us to learn from. So, as soon you get notification of the event or incident you should begin planning the investigation and proceed from there.

But when does an investigation end? Is it when the report is written, or when the recommendations have been accepted, or is it long after that, when the recommendations have been implemented? There’s no easy answer, but once the report has been written, the whole exercise has no value unless something changes thereafter. In the event of an unwanted incident, someone has to decide on what must be done to prevent the incident happening again. That may be the investigators, but it could also be the owner and recipients of the report who need to decide what controls, barriers and defences should be considered to prevent a
reoccurrence of the same or a similar event. Even then, the whole process is of no value unless these recommendations, SMART actions, if you like, are put in place, operate effectively, and are sustained.

So, we always remind our audience that a thorough investigation, followed by a clear and concise report, with SMART recommendations, is worthless unless something happens thereafter.

Consequently, we suggest you must ask these questions of your company:

  1. How are ‘learnings’ from the investigation categorised?
  2. How are they stored?
  3. How are they communicated?
  4. What short-term checks are in place?
  5. What long-term checks are in place?
  6. How will they be sustained?
  7. Have you made a difference?
  8. How do you know?

Once all the corrective actions have been put in place, and you are sure they are functioning properly, and will do so for a long time, only then can you rest easy, and say, ‘My investigation is complete, the job is done’.