Time poor, under pressure and lacking resources, it’s understandable that managers often undoubtedly feel the need to just get an investigation closed out following an incident, satisfied that procedures have been followed and things have been done ‘right’. This is especially the case for near misses that may seem inconsequential. But it isn’t enough to just ‘do’ the investigation and write up the report to be read and filed. Organisational learning and changes for the better won’t come from a safety culture that just pays lip service to incident investigation.
Part of having a good organisational safety culture means investing energy, time and money into training the right people to carry out thorough investigations that uncover all the causes, including the root cause, of any incident, large or small, real or potential. This demonstrates a commitment to safety and to the prevention of future incidents. Not only that, but having a trained investigation armoury with reliable tools will enable your people to investigate properly, thus saving wasted time and money on ineffectual investigations, which allow for further incidents to occur.
This, however, requires buy-in from senior management to spread the message that incident prevention is paramount, and therefore that investigations are taken seriously and should be carried out correctly. The accountability of leadership lies in absorbing, learning from, and making sure that recommendations from the resulting report and Root Cause Analysis are implemented and sustained. It also lies in being open to potentially unanticipated or controversial outcomes, which requires a willingness to see the bigger picture and to accept the unexpected. Trusting the investigators in your team to carry out the process properly means not being obstructive or defensive about their findings.
In order to investigate all incidents and near misses, these must be reported in the first place. Many organisations have open and ready incident reporting that’s ‘just the way we do things’, because it’s recognised that people need to know that reporting won’t lead to blame but to change and prevention. Just by knowing, through sharing and education, that any investigation is not about finding human culpability but about finding the inevitable human causes that led to the incident, imbues people with the right attitude for an investigation culture, and safety culture, to thrive.
Ideally, reporting becomes part of a cycle that then allows more investigations to be carried out, more causes to be found, and ultimately, leads to fewer incidents, and better employee engagement and productivity. Everyone in the organisation plays a vital and valuable role in this cycle, and the investigator is no different.