Blind Leading The Blind
Latest article by Phil LaDuke
So many studies have proven that eyewitness testimony is inaccurate. What does this say about incident investigations? In this week’s post on the Rockford Greene International blog I explore the how’s and whys of incident investigation. I would love it if you would give it a read and let me know what you think.
Read it here: http://rockfordgreeneinternational.wordpress.com/2012/09/02/the-blind-leading-the-blind/
Irrespective of whether you believe that worker injuries are rooted in behaviors or in system errors, most can agree that getting to the root cause of the injuries involves a complete and comprehensive investigation of exactly what happened. In almost all cases this investigation hinges on the eyewitness testimony of the injured party. Unfortunately, dependence on eyewitness accounts and the memories of injured workers sometimes impede incident investigation.
There is good reason to doubt the worker’s accounts of how they were injured:
- The Big Fish Effect. In the movie Albert Finney (and Ewan McGregor) play Edward Bloom, a dying travelling salesman who tells tall tales about his life. In his book, Why We Make Mistakes: How We Look Without Seeing, Forget Things In Seconds, and Are Pretty Sure We Are Way Above Average, Joseph Halliman, references many studies that cast serious doubts on the reliability of eyewitness accounts. (I cite Halliman a lot, his book is a great read and has a lot of information that every safety professional should know and apply.) According to Halliman, what most people think of as memories are actually idealized recreations of the facts and not true memories. Halliman references studies that show that people tend to remember their behaviors in the most positive light. This isn’t mere revisionism, people actually BELIEVE they behave more nobler and less culpable than they actually behaved.
Injured people are likely to remember taking fewer risks, following standard procedures more closely, and in general see their injury as completely unavoidable. - People Lie. People view injuries resulting from something they did—whether it be deliberate or completely outside their control—as a screw up, and nobody likes to admit that they screwed up. Halliman also shares interesting studies on the likelihood that people will lie even when they have no real incentive to do so. It’s like the old game of telephone where a spoken message is transmitted one at a time through a population. As each person relates the message to the next, it is subtly modified and molded until it is unrecognizable. The tale, I’m fond of saying, is tainted in the telling. In many cases we lie without any intention of deceiving another, but lie to reassure ourselves of the correctness of our position.
- We Frame Things In An Emotional Context. Our emotions play a big role in how we remember an incident. We tend to remember things we regret more profoundly than things of which we are proud. This would seem to support eyewitness accounts of injuries, but the fact that we remember things we didn’t do more acutely than the things we did creates confusions as we try to piece together what went wrong and caused and injury.
- We See What We Expect To See. You’ve probably seen illustrations of optical illusions—those drawings that befuddle our brains and make us see things that aren’t there. This same phenomenon can greatly confuse our senses and we will believe elements of an injury that are just not true.
- People Don’t Remember Unimportant Information. Studies have shown that it is very difficult for people to remember inconsequential information. In fact, it is extremely difficult for people to remember information that doesn’t have an emotional context.
Sometimes seemingly unimportant details are key to understanding how the system failed. Unfortunately, what seems unimportant to the worker before he or she is injured might be extremely important later. - We Subconsciously Frame Our Stories To Fit Our Beliefs. Framing is the practice of shaping our accounts of what happened to our beliefs of how they probably, or most likely happened. In effect, we decide how things happened and then remember details that support our world view and omit details that conflict with what we either consciously or subconsciously believe.
To combat this effect, safety professionals need to ask the injured worker to reenact (after every safety precaution is taken of course) the injury as closely as possible. The investigation may never reveal complete accuracy, but it is far more likely to provide a somewhat reliable account than a verbal retelling of the situation. - Memories are Contextual. Our Memories of an event are strongest in the context in which the event actually took place. Studies have shown that people taught a fact while they were underwaterwere far better able to recall that fact while underwater. What this means to for safety professionals is that incident investigations that are conducted in the actual work environment are likely to yield far more accurate results than those conducted in conference rooms or the safety office.
Our Memories Are Often Just Plain Wrong
Interviewing injured workers is likely to yield inaccurate and unreliable information so we can never rely on what a worker remembers or tells us to provide a useful account of an injury. Even so, there are things we can do to make incident investigations more effective and reliable:
- Focus On The System Failure, Not the Worker’s Behavior. Irrespective of your beliefs about the nature of injuries—process versus behavior—by focusing on how the process broke down instead of what the worker may have done to cause the injury you ease the incentive to lie. This in itself won’t make the worker’s memory more reliable, but it will lessen his or her desire to paint him or herself in a more positive light.
- Conduct All Investigations At The Exact Location Of the Injury. It may seem like an obvious action to take, but conducting investigations at the location at which the injury occurred is often missed. When we conduct injuries at a location removed from where the incident occurred we tend to view the scenario through the lens of what we think was true, or what should have been true. It is difficult to ignore factors that are present in the workplace when they are in our field of vision.
- Involve More People In The Investigation. This may seem counter intuitive but it is often useful to include people who have little or no knowledge of the process in the investigation. Because these people have no knowledge of how things normally work they tend to have fewer preconceived notions about how things were supposed to have happened. Outsiders also tend to ask those “stupid” questions that lead to important insights regarding the injuries.
Incident investigations and interviews with injured workers to ascertain the cause of injuries may not be perfect, but it is the best approach we have. Even so, it is important to remember that much of what we see and believe isn’t true and we are never so blind as when we believe that we see everything.
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