Investigating Events is NOT About ‘Brain Farts’
In Australia, we have this saying to try to explain why someone does something that doesn’t make sense, we call it a ‘brain fart’. It is a way of people accepting that someone did something that didn’t make rational sense and was out of the ordinary. There is actually a game on sale at Big W by this name (https://www.bigw.com.au/product/brain-fart/p/55569/). If you like you can read what Science tries to do with ‘brain farts’ see here: https://www.livescience.com/33841-10-everyday-brain-farts.html). How fascinating that most of this ‘science’ discussion is metaphysical ie. No logical or rational connection is made between the phenomena of ‘brain farts’ and enactment. Most of what is discussed is simply about miss-perception and the way humans envision (https://www.humandymensions.com/product/envisioning-risk-seeing-vision-and-meaning-in-risk/). Still, a good read for an industry consumed by behaviourism and scientism.
Incidents and events are not about ‘brain farts’ and, carrying such bias into an investigation is dangerous. This is what often sets safety apart from disciplines that understand interpretation and bias. The beginning of and good investigation is owning one’s own ethic and bias. Apart from the SEEK program (https://cllr.com.au/product/seek-the-social-psyvhology-of-event-investigations-unit-2/ ), I know of no Investigations product on the market that considers an ethic of risk, worldviews or bias in its methodology. The crazy assumption of Safety is that ethics are objective (see AIHS BoK on Ethics), causality is objective (see AIHS BoK on Causality) and that investigations are objective (see example: https://www.ioshmagazine.com/2021/06/15/how-conduct-effective-accident-investigation-interview).
The beginning of any effective investigation doesn’t start with Technique, it starts with self-reflection. Understanding one’s own personality type, learning style and cognitive bias is the starting point well before any investigation takes place. The investigator needs to understand what they are taking to the investigation and either share it with another very different ‘type’ or come clean about such bias before venturing into an investigation. There is no evidence of this in this proposal in How to Conduct An Effective Accident Investigation . Indeed, there are so many significant flaws in this article it serves as a case example of how NOT to conduct an investigation.
So lets have a look at what this article says:
- This article starts off by declaring the purpose of the investigator is to discover the ‘truth’ of enactment. And whose ‘truth’ would that be? Then comes a classic confession ‘the interviewee might have something to hide’. No thought that the interviewer is hiding anything, no hiding of ethics, assumptions and bias, such is the mindlessness of this article. What an amazing purpose in the opening paragraph: ‘But, with a careful approach, the interviewer can still keep the upper hand’. OMG, what is this ‘upper hand’? Good old Safety, always in control. Anyone worth their salt in counselling will tell you that interviewing is NOT about control but about giving power to the other.
- Typical of Safety this article concentrates on the mechanics of the interview room. By mentioning comparison to ‘police’ it is clear that this article is NOT about interviewing by interrogation. Particularly when it states: ‘Have ready access to any documents you might need: training records, service schedules, emails’. Then states that the focus of the interview should be ‘flow’, not likely. The best interviewer takes nothing into the room except sophisticated skills in open questioning, iCue Listening and an attitude of ‘humble enquiry’. This article is completely Interviewer-centric.
- The next stage of this article takes on the old favourite, behaviourism. Now Safety plats the role of behaviourist body language expert, this is simply dangerous. Without extensive education and experience over many years, making judgments about body language if fraught with danger and mis-judgment.
- Then the article goes back to policing and uses the acronym of PEACE as some kind of formula for interviewing. What a disaster. The last place to seek effectiveness in incident investigation is policing discourse. No wonder Safety is so attracted to this model. Has someone committed a crime?
- The next discussion in the article on ‘liar psychology’ is again very dangerous. Where is the Psychology experience and qualifications of the author (https://www.managementandsafety.co.uk/about/)? Oh that’s right, the Safety discipline makes one expert across all disciplines! Advising people about detecting lies is again police-talk and most dangerous advice for anyone conducting an investigation. Safety people are neither psychologists nor lawyers and the best advice is to NOT make judgements in this area. The beginning of effective event interviewing is to NOT interrogate people.
- The section on open questioning might be helpful if it was about open questioning skills but it isn’t. So, back to bias and worldviews. If you want to know about effective questioning perhaps go here: https://safetyrisk.net/questioning-skills-and-investigations/ With Safety identified as Zero, there is little hope that Safety would even know where to start with investigations carrying such bias. Just imagine how the bias of 1% safer (https://safetyrisk.net/1-safer-than-what/) with all its emphasis on numerics would drive an open investigation? It wouldn’t.
- One of the sure fire giveaways of Safety incompetence is this language of ‘soft’ and hard’ skills and this article confirms this. There are no ‘soft’ and hard’ skills, this is simply pejorative language that privileges engineering over person-centrism. There are people skills and non-people skills. Framing interviewing in any other way simply demonstrates safety’s bias to interrogation and policing. I certainly wouldn’t be going to the – ‘soft’ skills found in IOSH’s competency framework. Indeed, the last place to find the skills you need in effective interviewing is from the safety industry. When your ideology is zero, then anything that follows will be brutalism. Even the language of ‘competencies’ is anathema to the psychology of effective interviewing.
- The last section of this article finally suggest seeking specialist help. At last! And this won’t be found from the Institute of Industrial Accident Investigators. Just have a look at the Dreamworld fiasco (https://safetyrisk.net/an-engineering-dreamworld/) if you want to see what this bias manifests in investigation methodology. Perhaps read what a lawyer says about the Dreamworld fiasco (https://safetyrisk.net/safety-disconnect-and-the-dreamworld-tragedy/). Nothing could be worse than carrying into an investigation the bias of engineering, safety and a mechanistic worldview. No wonder the author believes in the naïve notion of independence.
- Of course, the semiotic of the cognitive maze at the start of the article matches the discourse of the article. However, incidents and events are never about ‘brain farts’ or ‘wrong cognitive programming’. This is the bias of traditional safety. Nothing could be further from reality and demonstrates the individualist, behaviourist and mechanistic view of the article. It is this semiotic that ‘frames’ such discourse. A simple look at this article and it’s omission about ‘culture’ is stark.
- Finally, let’s think about all that is missing in a Safety approach to investigations. In SEEK we call this the investigation donut. These are all the things that Safety never considers or understands as relevant to investigation (https://safetyrisk.net/the-seek-investigations-donut/).
There is much you can do to become effective in investigations but just as this article indicates, it won’t be found from Safety. There are indeed, many other ways of thinking about risk that the Safety worldview (https://safetyrisk.net/making-the-world-fit-the-safety-worldview/ ). This would require movement into a Transdisciplinary approach (https://safetyrisk.net/transdisciplinary-thinking-in-risk-and-safety/ ; https://safetyrisk.net/the-value-of-transdisciplinary-inquiry-in-a-crisis/ ) and this is not evident anywhere in the safety industry to date.