Incident Investigation and the Limits of Risk Imagination

Republished by Request

My favourite line: “Finally, we could spend a bit more time with our little kids and start practicing a way of thinking we have devalued for far too long and bring some fun back into making sense of risk.”

Incident Investigation and the Limits of Risk Imagination

‘Everything you can imagine is real’ – Pablo Picasso

I often get asked to investigate incidents from a cultural perspective. Whilst, most investigations focus on physical detail and sequence, I explore cultural and psychological causes. This is undertaken within the framework that incident investigations are about ‘fact finding’ not ‘fault finding’. Whilst all of the physical elements of investigation are most necessary I take a particular focus on what cultural and socialpsychological factors contributed to a physical outcome. I recently supported an organisation investigating their Lost Time Injuries (LTIs) over a 10 year period and determined that 90% of all their LTIs were primarily caused by psychosocial and culture factors. Their investigations has attributed causation to 90% physical factors.

Most of the key elements of what makes up culture are hidden. Culture is detected through physical indicators such as; symbols, artifacts, language, discourse, appearance and behavior. Culture is about these things but much more about the attitudes, values, mentalities and beliefs that are embedded in them.

For the purposes of this brief discussion I wish to look at just one psychocultural factor: imagination. Recently I was involved in an incident investigation and this was the primary cause. A culture that can’t imagine is an unsafe culture, a culture that can’t learn is an unsafe culture and a culture which under-reports is an unsafe culture. Imagination is one of the greatest resources organisations can access in the management of risk. Organisations and individuals that can’t imagine can only see in the ‘here and now’, such organisations struggle to doubt and entertain possibilities and therefore have poor capability in managing the unexpected.

So what do we know about imagination? Imagination steps beyond the confines of obedience and submission to standards, it understands them as a minimum. Imagination comes from experience, trial and error, play, experimentation, the vitality of faith, inquiry, critical thinking, storytelling, invention, creativity, reflection and the wisdom of what Weick calls ‘bricolage’. Imagination transcends the immediate and thinks of the unexpected, and knows how to do so.

Checklist thinking can only think about what’s in the checklist. In the case of this recent incident I investigated, there was no question in the safe work method statement about wind or changes in temperature, changes in climate or changes in combinations of these elements and so no one on the job could ‘imagine’ that these things would trigger a collapse. The learning and encouragement of imagination is not on the radar of many organisations. The enemy of imagination is busyness.

Just look at the last 20 OHS conferences you have heard about and see if the topic of the imagination is present in discussions about hazards, risk and safety?

I love spending time with my two granddaughters, one is 2 and the other 4 years of age. We play imagination games all the time: we make objects into mermaids; we become cats and dogs from cartoons; we sails across waters to the cubby house and hide in the corner of the bedroom from monsters. If we can think of it, we become it. The early years of childhood are all about imagination and it’s only later that our school system tries to knock such thinking out of them. It’s then we commence devaluing the imagination subjects such as art and music and elevate the importance of maths and science. By the time we get to our first occupation art and music are relegated for the majority of us to hobby status. Who would have thought that the same skills we engage in our hobbies would be so vital in making sense of risk.

I heard of a large company the other day after a series of incidents whose only solution to the problem of conformity to safe work method statements was to invent a checklist to check the checklist and then audit the checklist that was used to check the original checklist. Confused? Maybe not, but I’m sure the workers are. When we have 3000 safe work method statements on site and each one is 50 pages, we need to stop and ask what we are doing to ourselves and our imagination.

When it comes to the imagination and risk, here are a few things to consider, we need to:

1. Understand that systems-only thinking creates systems-dependent thinkers.
2. Change the mindset which tries to ‘engineer out idiots’. The more we keep this myth going, the more we create people on site who can’t think.
3. Think more about what is not on the checklist that what is in it. And for heaven’s sake, not just keep adding to the checklist.
4. Explore what is unseen just as much that is seen. We must ask the question in our safety observations: what can I not see or hear?
5. Limit language which only fosters small picture thinking. Zero talk for example creates micro-factor thinking. BP had maintained zero discourse for years before they couldn’t imagine what happened at the Deepwater Horizon Oil Rig in 2010. In fact, the week of the disaster they were bragging about their zero mantra.
6. Encourage exercises in imagining the unexpected, what Weick says is encouraging the ‘bad news’.
7. Speak much more about how we make sense of risk rather than generating fearfulness which limits imagination.
8. Take safety walks and conversation with no checklist but simply a blank paper and a host of open questions.
9. Spend more time in visual thinking, using concept maps etc. when we tackle problems and issues.
10. Bring people into our work groups who don’t think like us, who are outside the club, even outside our industry and ask them what they see.

Finally, we could spend a bit more time with our little kids and start practicing a way of thinking we have devalued for far too long and bring some fun back into making sense of risk.