Last blog we discussed the overall goal accident investigations – which is to improve the system. Too many times investigations stop short of this goal, simply because they found a way to prevent the last accident. This is a big mistake and an important reason why many organizations struggle continually with poor safety performance.
In this blog we’d like to address now how we actually investigate the accident. In terms of the “nuts and bolts” of the investigation there are actually six steps to an accident investigation:
- Secure the incident scene
- Collect the facts about what happened
- Understand the context of what happened
- Identify system deficiencies
- Recommend improvements
- Document the investigation
Lets take a look at each of these steps a little closer.
Secure the incident scene - As you likely have guessed, this is to preserve any evidence that is necessary to understand the accident. Obviously, if the investigation is happening in an organization our ability to secure the scene is limited because the organization likely wants to get things back up and running again as soon as possible. Try to get as much time as you can, but one way to make the process go faster is to take numerous pictures. This allows you to review the pictures later and develop context. Take lots and lots of pictures, much more than you think you’ll need. With today’s technology of digital cameras and camera phones this should not be hard. Remember – you’d rather have to delete a bunch of unnecessary photos than wish you had a taken more photos than you did. And, once you leave the scene, it is difficult to go back and take pictures later. Once you leave, you cannot be sure that the scene has remained secure.
Collect the facts about what happened – This will involve interviewing witnesses, reviewing documents, perhaps review security camera footage, etc. One thing you absolutely need to avoid is to make judgments about what happened at this point. The human mind is really good at making a judgment and then finding information that supports that judgment. In an accident investigation we call that hindsight bias. Unfortunately that leads to a lot of mistakes, especially in the investigation process. The problem, of course, is that no one is 100% unbiased. But this is why we need to actively resist bias, because the hindsight bias has a strong hold on us. Remember – the people involved in the accident did not know that what they were doing would lead to the accident. To them the future was uncertain. Keep that in mind as you collect the facts of the situation.
Understand the context – This is one of the most important steps in understanding what happened and then fixing the system. Behavior doesn’t occur in a vacuum. Things such as organizational goals, the culture of the organization, and even the physical features of our environment have an effect on what we do. Too many times accident investigations focus on human behavior and lead to the conclusion that “you can’t fix stupid.” However, if we look deeper we’ll often find that the environment that a person was in set that person up to make a “mistake” that then led to the accident. If all we do is point the blame at that person we’ll end up dealing with a similar mistake later because we didn’t fix the context, the system that the person was operating in.
Identify system deficiencies – Once you have a good understanding of the facts of the specific incident and the context that the incident happened in you’ll be in a good place to identify what the deficiencies were in the system that allowed the accident to happen. Remember – the purpose of our investigation is to identify problems in the system, not in people. If the only problems we find are with people then we’re missing something.
Recommend improvements – Based on the problems you found, identify corrective actions. For specific items, remember to use the hierarchy of controls that we talked about in a previous blog. For any improvements make sure that you consider unintended consequences. If you implement a new procedure but that procedure actually introduces new risks you might not have improved anything.
Document the investigation – Last, but not least, document the investigation. Usually this is done in a report form for more serious investigations. Each organization will have different procedures and formats that they use. One recommendation though is to figure out what format and forms you want to use now, before the investigation starts. You don’t want to figure out what documentation you’ll need while you’re trying to do an investigation. Consider other stakeholders as well. Does your insurance company need documentation from you? What about OSHA or some other agency? If you’re a contractor, what does your customer want to see? If you work with the public, would there be any information released to the public? Make sure you plan as much as you can now, while you don’t have the stress of an accident on your mind.
As we’ve discussed, investigating accidents is an extremely important part of any safety system. Take some time to digest the information in this blog and the previous one. Share your thoughts in the comments section below. Are there other things that must be considered in the investigation process? The important thing is that you have a clear strategy in place before the accident happens!