Top 10 Mistakes Incident Investigators Make
1. They rush in:
Investigators often rush in immediately and do not give time to thinking through the best way forward: people to be involved in the team, timing of task, who to do what etc. Nothing is gained and much is lost by proceeding in a rushed or haphazard fashion. Collecting the data and the analysis yield much better results if approached systematically.
2. They want answers NOW:
Investigators, as well as being in too much of a hurry, are often too eager to arrive at the answer, the want to know ‘what went wrong’ NOW. The underlying and root causes of accidents are not necessarily simple or single causes. Time taken now will pay off in the thoroughness of your investigation and accuracy of your findings.
3. They are ‘lone wolves’:
Seldom does doing a complex task alone work or yield satisfactory results. This is especially true in investigation where different ways of looking at things and active discussion are crucial.
4. They make assumptions:
This follows on from Number 3. We all see the world filtered through ‘who’ we are. And there is nothing wrong with that; that is how things are. However, in an investigation we have to challenge assumptions. Nothing is obvious or can be taken for granted. That is where colleagues and the team come in. Your Storyboard and Root Cause Analysis charts also ‘tell the story’ visually. It is clearer as you revisit them with others and discuss what you think happened, to challenge any assumptions which jump out at you.
5. They look for the ‘culprit’:
If you wade in making it clear that ‘someone has to hang for this’ you might as well give up your investigation at the start. Nobody will cooperate or tell you anything. That is not the same as expecting someone to take responsibility. To learn is part of the reason for the investigation in the first place. Admitting that we learn from error is the first step to making improvements in safety.
The next step is acknowledging the errors themselves.
6. They discount the naïve idea:
When a well known European company was searching for a new way of approaching a tunnelling job in the Netherlands to take account of the very wet terrain, their experienced research and development engineers drew a blank. It was when they went and talked to primary school children that the children provided them with the breakthrough innovative, and very simple idea. The company provided the eventual engineering but the straightforward idea came from children.
7. Because they are the ‘boss’ they think they are right:
Many a project or investigation is sabotaged by this sort of arrogance. Much more effective is the kind of team leader who has polished their coaching style so that they can draw the best out of the team. That is the sort of investigator (or boss) who is worth their weight in gold.
8. They treat a reporting form as an investigation tool:
A Root Cause Analysis can only be as good as the information fed into it from the investigators and the Storyboard Chart. It is no use going to a report form and ‘ticking the box’ in order to generate an investigation report; only totally useless information will emerge. The whole point of the TOP-SET® method of investigating using the indicators is to guard against this distortion and to provide reliable input. Then you can do the Root Cause Analysis which will be the meat for your report and generate reliable information to act upon.
9. They stop at the ‘immediate causes’:
Too often, according to the regulator, investigators think that they have arrived at the causes of an accident when all they have done is identify ‘what happened’ in terms of immediate causes e.g. ‘The car didn’t stop at the lights and hit the woman on the crossing’. In order to stop that happening again, it is not enough to prosecute the man and take his license away. Stopping similar occurrences, not just that specific accident, from happening again is the goal, and the investigation must drive down from the immediate causes, asking the question ‘why’ all the way until there are no more answers. The Kelvin TOP-SET system shows you how to do this and how to create the information - underlying and root causes - to help you recommend measures to prevent many more related further incidents.
10. They don’t investigate and sack the guy who ‘did it’:
The Buddhists have a teaching called ‘mutual arising’ which means that no one - nobody and no thing - is to blame for anything that ever occurs, because all is ‘mutually arising’. Even a war, a terrorist attack is ‘mutually arising,’ it is not simply the ‘fault of a person or nation’. This idea is actually at the bottom of why we need to investigate. No one thing is ever responsible for any event, good or bad. Things and people are all in relationship with one another all the time. It is that relationship which causes things, good and bad, to arise or to happen. And it is to discover how that relationship was working at the time of any incident that is the purpose and goal of the investigator.