Incident Investigations and the Einstellung Effect

imageWe all know about the psychological concept of ‘conditioning’. It doesn’t matter whether the conditioning is classical or operant , humans develop habits and heuristics to ensure comfort, safety, efficiency and security in daily living. Whilst there is some element of truth to the behaviourist assumptions of conditioning, this doesn’t explain a great deal about why people do what they do, because behaviourism is founded on a limited mechanistic and naïve anthropology.

Without an understanding of the social influences on humans one will tend under behaviourism, to assume that human action is reductionist (reducible down to the simplest part), linear (swiss cheese) and logical (think accidents happen because people are stupid). This is far from the case (https://scholar.harvard.edu/files/jenniferlerner/files/annual_review_manuscript_june_16_final.final_.pdf ).

We do know however that often the very things we think will work in safety do the exact opposite eg. homestasis (https://safetyrisk.net/the-shock-of-homeostasis/ ). Another example you may not have heard of is the ‘Einstellung Effect’ (https://www.khanacademy.org/test-prep/mcat/behavior/learning-slug/a/classical-and-operant-conditioning-article). In 1943 Abraham Luchins through experiments like the ‘water jar problem’ (https://www.tandfonline.com/doi/abs/10.1080/00224545.1961.9922159) demonstrated that humans have the tendency to develop a ‘mechanised state of mind’ when it comes to problem solving.

One of the profound weaknesses of a STEM-only approach to knowledge and skill development that is dominant in the indoctrination of the safety curriculum, is the ability to think critically. The safety curriculum teaches students that events can be reduced to smaller parts, that events are linear and that humans are the sum of inputs and outputs. These assumptions are also common to all incident investigation methods on the market.

The Einstellung Effect shares some commonality with Ockham’s Razor, that humans tend to find solutions as efficiently as possible. The opposite of the Einstellung Effect and Ockham’s Razor is the notion of Wicked Problems (https://safetyrisk.net/risk-and-safety-as-a-wicked-problem/). The best way to respond to a Wicked Problem is through Transdisciplinarity (https://safetyrisk.net/transdisciplinarity-and-worldviews-in-risk/). When problems are more like a rhizome (https://safetyrisk.net/like-a-rhizome-cowboy/ ) than Reason’s swiss cheese, reductionist methodologies and behaviourist anthropologies simply won’t do.

When it comes to incident investigations one needs few of the assumptions of the current models of investigations on the market. Rather than investigation what mostly happens with these popular models is, confirmation of what is already assumed. Have a look at your favourite model of investigation and see what is discusses about:

· Human perception (https://safetyrisk.net/foundations-of-perception-and-imagination-in-risk/)

· Cognitive and social psychological bias

· The assumptions of the investigator

· The personality type of the investigator

· The dialectic of consciousness-unconsciousness

· Heuristics and habit

· Semiotics and visual influencing

· Wicked Problems

· Transdisciplinary ways of understanding decision making

· Cultural dynamics

· Pastoral care skills in investigating and,

· Cognitive dissonance

If these are not on the agenda and a part of investigation methodology, it is most likely going to be a pretty inadequate model of investigation.

The SEEK model of incident investigations opens up a whole new world of critical thinking, tackling human bias in investigation, social influences on decision making and thinking differently about event construction.

https://cllr.com.au/product/seek-the-social-psyvhology-of-event-investigations-unit-2/

If you or a group are interested in learning how to SEEK contact rob@humandymensions.com

Rob is proposing to deliver a public workshop on SEEK in Belgium on 1,2 June 2020 (https://safetyrisk.net/european-tour-dr-long-1-5-june-2020/ ). You can register your interest for this workshop here: rob@humandymensions.com

Dr Rob Long

Dr Rob Long

Expert in Social Psychology, Principal & Trainer at Human Dymensions
Dr Rob Long

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Dr Rob Long
PhD., MEd., MOH., BEd., BTh., Dip T., Dip Min., Cert IV TAA, MRMIA Rob is the founder of Human Dymensions and has extensive experience, qualifications and expertise across a range of sectors including government, education, corporate, industry and community sectors over 30 years. Rob has worked at all levels of the education and training sector including serving on various post graduate executive, post graduate supervision, post graduate course design and implementation programs.

22 Replies to “Incident Investigations and the Einstellung Effect”

  1. If any of you have been the victim of an ICAM or TapRoot auto da fe using the mechanistic funnelling technique conducted by an accredited witchfinder general just imagine the torment endured by the person of interest in the following police investigation:

    1. Bernard, it’s very much about the closed nature of the safety industry as is evidenced by the BoK. If you keep going to the same watering hole, the water will always taste the same. That’s the comfort of the fortress, no questions, no debate and no dialogue, just the safety of zero. If sausages are the only thing on your dietary knowledge then snags are all you know.

        1. Was at Bunnings last week and all that pressure to be safe with onions etc was gone, people were focused on the bushfires and people, conversation and listening, although I nearly was run over twice!

          1. and you can still walk in and buy a chainsaw or a 9″ angle grinder from a jnr assistant with no questions asked and no warning info or instruction given

  2. From a standpoint of a fair and just culture, as soon as you say, “incident investigation”, you’re behind the curve. What do you think will get more information, “I’m here to investigate the incident” or “I’m here to analyze the event and I need your help to make sure it never happens again”? I’ve found it’s also better to use cognitive interviewing and let the individual tell their story than to ask closed-ended questions.

    1. Thanks Jim. I’m not sure what curve you refer to but the notion of investigation or the language you use depends of the culture and methodology of the process. Context often defines meaning and purpose and need not make the word investigation perjorative? Investigation often implies critical research, analysis, examination, study and engagement rather than inquisition. Similarly the language of fairness and justice are just as conditioned by culture. Asking for help is good but the underlying methodology may not change, Safety rarely talks about ‘helping’ anyway eg. AIHS BoK on Ethics. The whole Just Culture thing too is often about deontological ethics (duty, rules) and usually results in a behaviourist form of brutalism, again see ethics in the AIHS BoK.

      I think we can ‘investigate’ an ‘incident’ without ‘interrogating a person’ which is why the SEEK program focuses on social psychology, that is how social arrangements affect decision making.

    2. I’ve found that something like “what did you learn?” can be more effective – but, as Rob said, it depends on the context. I usually get involved these days well after the event when financial consequences are being considered and negotiated (ie claims and future insurance premiums). The word “learn” may be universally more user friendly than “investigate”

      1. Yes, the question of learning ought to be foundational but unfortunately learning gets next to no mention anywhere in safety, it is simply not part of the discourse. The AIHS Bok on Ethics is a classic example. Again, you can go to schools where learning and education are intended to take place and all there is only indoctrination, the opposite of critical thinking and learning. Whilst they use the language of ‘education’ and ‘learning’ that isn’t the culture, there must be congruence between language and culture for language to have meaning. Similarly the government use the label iCare for NSW compensation, and there is little care.
        When people come to find out things we usually call them ‘Investigators’, in itself it need not be a pejorative word, it is again the culture and methodology that make the method.
        I am often involved in research and findings post events, this is well after all the blame has died down and I apply my SPoR lens to the situation and rarely find much congruence with the original investigation, the risk and safety industry with its STEM-only lens simply doesn’t ask the questions I ask or see what I see. It’s about worldviews and applying a transdisciplinary approach that matters.

  3. There are so much to a Safety Management System that keeps safety professionals behind a desk. Such an archaic process but very required. I have witnessed many safety people pigeon hole themselves into an office to write policy, procedures, without walking the environment/facility to clearly understanding the work, tasks, hazards presented.

    1. Bernard, it’s very much about the closed nature of the safety industry as is evidenced by the BoK. If you keep going to the same watering hole, the water will always taste the same. That’s the comfort of the fortress, no questions, no debate and no dialogue, just the safety of zero. If sausages are the only thing on your dietary knowledge then snags are all you know.

        1. Was at Bunnings last week and all that pressure to be safe with onions etc was gone, people were focused on the bushfires and people, conversation and listening, although I nearly was run over twice!

          1. and you can still walk in and buy a chainsaw or a 9″ angle grinder from a jnr assistant with no questions asked and no warning info or instruction given

  4. There are so much to a Safety Management System that keeps safety professionals behind a desk. Such an archaic process but very required. I have witnessed many safety people pigeon hole themselves into an office to write policy, procedures, without walking the environment/facility to clearly understanding the work, tasks, hazards presented.

  5. From a standpoint of a fair and just culture, as soon as you say, “incident investigation”, you’re behind the curve. What do you think will get more information, “I’m here to investigate the incident” or “I’m here to analyze the event and I need your help to make sure it never happens again”? I’ve found it’s also better to use cognitive interviewing and let the individual tell their story than to ask closed-ended questions.

    1. Thanks Jim. I’m not sure what curve you refer to but the notion of investigation or the language you use depends of the culture and methodology of the process. Context often defines meaning and purpose and need not make the word investigation perjorative? Investigation often implies critical research, analysis, examination, study and engagement rather than inquisition. Similarly the language of fairness and justice are just as conditioned by culture. Asking for help is good but the underlying methodology may not change, Safety rarely talks about ‘helping’ anyway eg. AIHS BoK on Ethics. The whole Just Culture thing too is often about deontological ethics (duty, rules) and usually results in a behaviourist form of brutalism, again see ethics in the AIHS BoK.

      I think we can ‘investigate’ an ‘incident’ without ‘interrogating a person’ which is why the SEEK program focuses on social psychology, that is how social arrangements affect decision making.

    2. I’ve found that something like “what did you learn?” can be more effective – but, as Rob said, it depends on the context. I usually get involved these days well after the event when financial consequences are being considered and negotiated (ie claims and future insurance premiums). The word “learn” may be universally more user friendly than “investigate”

      1. Yes, the question of learning ought to be foundational but unfortunately learning gets next to no mention anywhere in safety, it is simply not part of the discourse. The AIHS Bok on Ethics is a classic example. Again, you can go to schools where learning and education are intended to take place and all there is only indoctrination, the opposite of critical thinking and learning. Whilst they use the language of ‘education’ and ‘learning’ that isn’t the culture, there must be congruence between language and culture for language to have meaning. Similarly the government use the label iCare for NSW compensation, and there is little care.
        When people come to find out things we usually call them ‘Investigators’, in itself it need not be a pejorative word, it is again the culture and methodology that make the method.
        I am often involved in research and findings post events, this is well after all the blame has died down and I apply my SPoR lens to the situation and rarely find much congruence with the original investigation, the risk and safety industry with its STEM-only lens simply doesn’t ask the questions I ask or see what I see. It’s about worldviews and applying a transdisciplinary approach that matters.

  6. If any of you have been the victim of an ICAM or TapRoot auto da fe using the mechanistic funnelling technique conducted by an accredited witchfinder general just imagine the torment endured by the person of interest in the following police investigation:

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