Just Get to the Bottom of it

by Rob Sams on November 5, 2016

in Rob Sams



Just Get to the Bottom of it…..

Republished by request……….

butt kickAn incident occurs at work, the well entrenched procedures quickly kick into play – first aid provided, forms filled in, reports to management, find the cause (sometimes causes), change operating procedures (they must have been wrong), issue Safety Alert and conduct Toolbox Talk, include information on monthly report, then file.

Our systems and standard processes, some argue even the legislation, often dictate that this is what we should do, so we just do it. Sound familiar?

The question is, if following this type of systematic approach is the only way we go about things following an incident, do we limit the opportunity we have to learn from the incident? Could it be that the more mechanistic our response, the less we ‘think’ and reflect humanly about what has happened?

Traditional approaches used within the safety profession following an incident typically use a mechanistic method of review. For example Taproot, ICAM, Ishikawa or Fishbone Diagrams and 5 Why’s are all popular tools used by the profession to guide incident investigations.

These tools differ in a number of ways, but the one thing they have in common is that they demand a systematic and mechanistic approach to investigation. What is more, all these approaches to investigation assume that social-psychological factors are not a necessary factor in human decision making. Each of these systems of investigation not only proposes a ‘method’ but has its own underlying methodology or philosophy bias about humans. The majority of incident investigation approaches understand the human as a rational being and have no factor in their mechanistic structure to understand the way social psychological factors shape judgement. This has the effect of priming users to focus on ‘things’ and the quest to find ‘root causes’ as if incidents are solely an engineering process. Mechanistic and systematic approaches can be useful to assess engineering and forensic factors, but can they really understand and explain the nature of human decision making associated with an incident?

While some of the tools listed above include elements of ‘human factors’, they typically focus on how humans made ‘errors’, ‘mistakes’, ‘lapses’ and ‘failures’. While there is much written about “Human Factors”, notably by people such as Reason (1990) who came up with the “Swiss Cheese Model”, the attribution that people (aka humans) involved in an incident made an ‘errors’, ‘mistakes’, ‘lapses’ or ‘failures’ prime those investigating the circumstances of the incident to think negatively about the incident and about the human. The worst thing is, that because the mechanistic approach assumes a rational logical human, it doesn’t understand non-rational factors that influence decision making. The rational assumption thinks that any mistake or error has an element of intent or .fault’. That is, something must have gone ‘wrong’, someone didn’t do what was expected of them, we must find fault. When we have found fault, we can come up with recommendations and controls, job done, right? How satisfied would any organisation be if the investigation found no fault?

The effect of this is that incident investigations, or at least the results of them, become predictable. I wrote about heuristics in my last piece (https://safetyrisk.net/i-wish-i-had-thought-of-that/) and in particular the “availability heuristic” and the impact that this can have on risk assessment. The same effects can occur in incident investigation. Have you ever been in a situation where you have been investigating an incident and a familiar pattern becomes obvious to you, something like… the person didn’t follow the procedure, they hadn’t been trained, the machine wasn’t serviced, the list goes on. What impact did the availability heuristic have when you were conducting an investigation? Did it limit your thinking? Did it do what a heuristic is designed to do and take you on a ‘mental short-cut’ that lead you to a conclusion, limited your thinking and with that, limit your opportunity to learn?

Unfortunately, a mechanistic approach to investigating incidents constrains investigative thinking because factors such as the availability heuristic mean we must ‘just get to the bottom of it”, find those root causes, as quickly as possible.

Why is it then that we continue to adopt only mechanistic approaches when reviewing incidents? Perhaps one of the reasons that the person did not follow the procedure was that they were distracted – by a noise, because they were thinking about the footy, because they were bored in their job, stressed or running on autopilot. How will we discover these things if we only ask mechanistic (and often closed) questions about procedures, training, maintenance, and errors linked to process failure? Imagine the information we could learn if in addition to looking at systemic processes, we had an open conversation with the person, or persons, involved in an incident. What if we didn’t focus just on asking questions such as five why’s, six whens, four how’s, or whatever process is in place, and talked less and listened more with people. Maybe one of the outcomes of such an approach would be that they would open up, they would not feel like they are being interrogated, they would not become defensive, and they may tell us what was really going on rather than tell the investigator what they want to hear..

Of course to take a non mechanistic approach requires courage and imagination. The focus would be on the conversation not just the system, we may need to overcome some fears of our own. We may even realise that too much of our subjectivities are brought into our investigations. We may then become much more aware of the types of conversations we have with people. What if we are talking with a young person following an incident and they tell us that they were thinking about the date they have planned for Saturday night, that’s one of the reasons why they didn’t hit the right button. How do we respond to that? To the rationalist assumption, this is hard top explain, we then find fault that they ‘didn’t have their mind on the job’.

I have talked to many safety, and HR professionals who say “just don’t go there”. I’ve had union officials say “you can’t ask about that, what happens outside of work has nothing to do with what happens here”. Concerns about the response we might get when we engage in open dialogue can limit our opportunity to learn. Imagine if the police were to adopt this approach? There aren’t too many crooks who wander into police stations and profess their sins. Good detectives engage in good dialogue, ask good open questions, people talk and they listen. This is how they discover so much of what they are looking for. Start with questions, gather information, and open up a conversation about confessions.

Systems can play a role when trying to understand the factors that contributed to an incident, but we need to recognise their limitations. The standard approach to gathering facts, reviewing procedures, training records and maintenance documents will all help understand some of the contributing factors. However if we continue to use only mechanistic methods when reviewing incidents, we will continue to limit our learning. Instead, we need to suspend our own agenda’s, be aware of our own biases, and recognise the impact of heuristics, and talk more to people, engage in conversation and most importantly listen to what people are saying. Let people tell us what really went on, without fear that they will be seen to have failed, or be “at fault”. If we follow this approach, perhaps the contributing factors will become not only obvious to us, but better still, to the person, or persons involved in the incident, and they will learn too.

Robert Sams

P: 0424 037 112

E: robert@dolphinsafetysolutions.com

W: www.dolphinsafetysolutions.com.au

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Rob Sams
Rob Sams

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Rob Sams
Rob is an experienced safety and people professional, having worked in a broad range of industries and work environments, including manufacturing, professional services (building and facilities maintenance), healthcare, transport, automotive, sales and marketing. He is a passionate leader who enjoys supporting people and organizations through periods of change. Rob specializes in making the challenges of risk and safety more understandable in the workplace. He uses his substantial skills and formal training in leadership, social psychology of risk and coaching to help organizations understand how to better manage people, risk and performance. Rob builds relationships and "scaffolds" people development and change so that organizations can achieve the meaningful goals they set for themselves. While Rob has specialist knowledge in systems, his passion is in making systems useable for people and organizations. In many ways, Rob is a translator; he interprets the complex language of processes, regulations and legislation into meaningful and practical tasks. Rob uses his knowledge of social psychology to help people and organizations filter the many pressures they are made anxious about by regulators and various media. He is able to bring the many complexities of systems demands down to earth to a relevant and practical level.
  • Mark

    Rob, this is why the sad truth of the collective matter is that many people are bound by far more that what we think we can change. The world is and never will be perfect and we do not value human spirit.

    The people who visit to this site, who write varied topics, are the most passionate people, but we only make up a small percentage of what’s out there in the real world. I get what your saying, it is about goodness and respect and all things virtuous, but, we have many people who just don’t care for others.

    Do give up your thoughts or fear judgment by the many cynics.

    Keep fighting the good cause.

  • Robert Sams

    Thanks for the comments Rob and Mark, they are valuable in my ongoing journey of learning.

    Mark, if you don’t mind, I’ll respond mostly to your short answer. I think your right, one off the key attributes that a safety professional needs to have is courage, it sure does take courage to talk openly and frankly with senior management. You raise some good points about time and priorities too. I wonder if this is in part a matter of prioritising what people spend their time doing and where they focus their own development. Our profession might be viewed differently if we focused on learning more about how to ask good questions, which I reckon is more than just ‘why’ (which sometimes can be just another way of telling – I think it was you made that good point in one of my previous posts).

    You’ll probably notice that one of the central themes in all of my posts is that I believe that we “de-humanise” so much at work, even when we talk to people, it’s like we are talking to an object. My hope in writing these posts is that people is that our profession will open up to new ways of thinking beyond our traditional approaches to safety which is focused on trying to motivate people through fear and systems, and learn more about other ways that people may be motivated. Cheers, Rob Sams

  • Mark

    Short reply…

    This post does raise some key issues. You have basically pointed to the underlying fact that people who investigate incidents are not fully competent incident investigators, if they were, then listening would not be an issue. The hidden realist fact is that people inside a company are not always allowed to find the real truth, as it might upset certain people who are not doing their job. Imagine telling a CEO or a manager that they have failed to provide a safe workplace…it would be bye bye. This is why people (safety and HR) tell people to “not go there”.

    Long extended reply…

    You can go and complete a one or two day course on incident investigating and then be called an “incident investigator specialist”. I don’t think police detectives are trained in two days and I don’t think many businesses would send their workers to university either to learn how to conduct investigations, which would include how to ask and frame questions which are designed to find the real causal factors.

    Just stop and think for a second what you are pointing out (lack of skill); if a company was to train say 20 safety people to be really proficient and competent in everything their job description expects them to be, how much time do you think these people would actually be on the job? How much money is it going to cost the company to train up all these people? A company is to be profitable, this is reality. Auditing is another key role the safety person is supposed to do, but this skill is also greatly lacking and contributes towards many incidents. If the company is not going to pay for and allow time for this training, do you really expect that all people are going to spend their free time studying things that are not required, because the basic stuff will suffice. People are time deprived as it is. There are safety professionals out there right now that do not even know that the OHS Core Body of Knowledge and ISO 31000 even exists, this is basic stuff, yet these very people look after safety and are tasked to conduct incident investigations!

    How many thorough, accurate, incident investigations do you think are really allowed in most workplaces? Do we really think that a company such as BP (Macondo) would find fault in themselves without external investigations? Pike River; if the investigation was only done by Pike, do we think the report would have included all the real causal factors; it would come out as worker error with the truth well hidden.

    I have been involved in the 24hr time governed incident reports (Needed by ? time) that have listed the real causal factors, only for them to be edited down and made into an operator error causality report, with no fault attributed to management. For example, I did an incident report for major contractor at the new Gold Coast Hospital when a worker fell off a ladder. I handed the report to the clients safety manger, and after a few hrs, I was told off the record it was great report and true…but…for the record, I had to alter the causal factors and make it the fault of the worker because the Ops manager would not accept it the way it was (which was based off the facts presented by the IP and witnesses). The client simply did not want a bad tick against their name, this goes on everywhere…subsequently I left this employment. Another incident investigation I was involved in was a roller tipping over due to running off the edge of a road in the dark (nightshift). I was told by my HSE manager to say that it was operator error (was not concentrating). The facts I found though told a very different story; lack of lighting (no lights facing down on the road), fatigue (11hrs operating a roller, operator had done a double shift), and the black bitumen edge of the road at night had no distinguishable visible edge (it was hard to see where the road edge finished, and could not see the drop off) …subsequently I left this employment. Now, if this was a death, these facts would have been discovered by OHS inspectors, but no death, no truth needed…operator error…will happen again…may kill the next time…company did not want to learn or accept the truth.

    The only tools available to people who investigate incidents are RCA etc, and while they might be systematic and mechanistic, they are designed to be built up from information that is supposed to be objectively collected by competent investigators, this is the only way they can be constructed. Even chaos looks systematic if you put it into a maths equation, even seemingly random events if studied can appear on paper as if there is a pattern.

    The 5-whys is a listening tool, you ask why and others tell you what happened. The apparent ease of the 5-Whys leads people to use it, but its apparent ease hides the complexity in the methodology it prescribes and people can unwittingly apply it wrongfully. The issue here is the lack of competence of the investigator, not the tool itself. The 5-whys does not assume that mistakes or errors have an element of intent or fault. It seeks to find why things happened. You cannot find answers if you don’t ask why.

    You are correct in saying we need to hear people, but, in the real world, hearing is not something that is freely permitted (or least for real issues), its cover thy ass (CTA) that rules. The reason why we have CTA…the legal system and the fear it invokes. Until the legal system changes and peoples right for compo is void (even when they trip over on their way to lunch), things are not going to change.

    Something we need to debate openly is this whole fault and blame topic that keeps coming up. Has anyone ever done an incident report where no causal factors faults where found? There is fault (or a series of simultaneous faults) in every single accident. And if anyone can challenge this, please tell us your defence. If a worker is thinking about Friday night and this worker actually tells the investigator this was why they pushed the wrong button, then the fault is lack of human perfection. Whether this lack of human perfection is worthy of fault is a different story. If we start say that all incidents are just because humans make mistakes due to heuristics etc, then we defiantly won’t find causal factors, because everyone has an easy option to just avoid truth.

    “Smudge” the good cynic

  • Well written Rob and extracts some key issues associated with common approaches to incident investigations.

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