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!
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