Best practice Lessons in Incident Investigation
This article was first published by the Safety Institute of Australia and appeared in OHS Professional, Sept 2018.
OHS Professional speaks with Joanne De Landre, COO of Safety Wise, about the latest trends in effective incident investigations and how OHS professionals can reduce safety risks in the process.
How well do most organisations, in general, approach incident investigations?
It is encouraging to have seen great improvements generally across industries in relation to incident investigations over the past several years. However, admittedly for some there is still plenty of opportunity for improvement.
In the “old days” we saw plenty of incident investigation reports where, after the incident description and a couple of photographs, we’d turn the page to see the word “Finding” – no “s” on the end. Under this heading we’d often see two words – “Operator Error”… While this may have been true in the strictest sense of the words (i.e. that the operator committed an error), it was of little value in explaining why the incident occurred and of absolutely no value in preventing a repeat incident. Contemporary investigation methodologies look deeper into the organisational factors that contributed to incidents.
Organisations need to always keep in mind that incident investigations are about determining what happened, why it happened and how we can stop it happening again. After all, the raison d’être of an incident investigation is prevention of recurrence and reduction of risk. There’s nothing worse than responding to a repeat incident, seen as a secondary that is tacked on to a primary role. People are often so busy with their normal “day job”, yet there is the expectation they can also manage to juggle an incident investigation at the same time. Organisations need to ensure sufficient resources in terms of people, time and soon, are allocated. Incident management procedures/protocols: Without formalised processes it is difficult for those undertaking incident investigations to know exactly what to do in terms of the investigation itself as well as being aware of timeframes, reporting frameworks and so on. All organisations should have an effective Incident Management Procedure specific to their operations. Those personnel nominated as investigators should be familiar with the requirements and protocols. Lack of transparency/feedback: Without knowledge of contemporary investigation processes, there are still many workers who fear incident investigations and immediately perceive it as a punitive particularly when it involves major harm or loss of people, to find that previous occurrences had not been investigated well and recommendations were not aimed at prevention of recurrence. It’s a very sad feeling to know that a significant incident could have so easily been avoided if previous incident investigations and associated recommendations had been effective.
Where are the most common gaps in incident investigations?
The most common challenges in relation to many organisations’ approach to incident investigations include a variety of systems issues that can be easily rectified, including:
Training: I’ve lost count of the number of attendees at ICAM training courses who make the comment during the introductions: “Well, I’ve been doing investigations for a few years but haven’t been formally trained. So I’m here today to make sure I’m actually doing it right.” Anyone nominated as an incident investigator should be trained in the process to ensure they have knowledge of the method and be able to avail themselves of experienced personnel to guide them through until they are assessed as competent.
Time/resources: The role of an incident investigator is often seen as a secondary role that is tacked on to a primary role. People are often so busy with their normal “day job”, yet there is the expectation they can also manage to juggle an incident investigation at the same time. Organisations need to ensure sufficient resources in terms of people, time and so on, are allocated.
Incident management procedures/protocols: Withoutformalised processes it is difficult for those undertaking incident investigations to know exactly what to do in terms of the investigation itself as well as being aware of timeframes, reporting frameworks and so on. All organisations should have an effective Incident Management Procedure specific
to their operations. Those personnel nominated as investigators should be familiar with the requirements and protocols.
Lack of transparency/feedback: Without knowledge of contemporary investigation processes, there are still many workers who fear incident investigations and immediately perceive it as a punitive process. There needs to be greater transparency so the workforce are aware and can see that the investigation process doesn’t just focus on the actions of operators but
delves back into the conditions that may have influenced them and the organisation’s protocols and practices. If the methodology gains the trust of the workforce, it can improve the reporting culture.
What are a few hallmarks of “best practice” incident investigation?
Organisations with best practice incident investigations, above all, have management commitment to the process. They do not take a reactive approach and just deal with events as they happen. They ensure that they are prepared and review the effectiveness of their processes and systems on a scheduled basis. They ensure there is a consistent approach to incident investigations and that they have quality standards for both the investigators and for the approving officers. They ensure that they have a process for learning lessons from incidents and that recommendations
are seen as the opportunity to identify “error tolerance” improvement opportunities. Systemic investigations are seen as providing meaningful and useable data to promote aggregated learnings.
What are the implications in the above for OHS professionals?
I would suggest to OHS professionals that they keep in mind the very important and critical role of incident investigation. While it might simply be seen as a process, it really should be seen as a
critical role that can mean the difference between repeat events happening or not.
If an incident investigation is not done well, if the recommendations do not address all of the contributing factors… then the door is left open for a repeat incident – and that repeat incident could well be an escalation that results in someone getting hurt or worse. Anyone appointed as an incident investigator should keep in mind that ultimately they’re looking after their wellbeing and that of their mates, their colleagues. Incident investigators should feel comfortable after each incident investigation that they have done their best in achieving prevention of recurrence and reduction of risk.
What steps can they take as a result? Advice for them?
Adopting a particular investigation analysis methodology is only one part of what we need. Hand-in-hand with that, there are additional measures to ensure we are striving for optimal safety
performance and operational excellence. In relation to incident management we need to ensure we have underlying or foundation documents and systems in place. Including references, for example, in t he company charter, HSE policy standards, procedures, templates and so on. Do your personnel appointed as investigators know the processes, know where the forms are? Are both actual and potential consequences considered?
Incident reporting is critical. Do you think you’re getting to hear about all the incidents? What are some road blocks that may exist to reporting (for example, perception of punitive culture, too hard to report incidents, takes too long)?
Corrective actions management process. When do you close-out the investigation process? Do you have a system to ensure that close-out doesn’t occur until actions are:
(a) approved – subject to a change management
(b) validated that they are actually done; and
(c) have been reviewed for effectiveness after they are put in place operationally
Metrics and tracking.
Are incidents looked at one by one or is the true value of all incidents considered systemically? Incident management databases are not just for entering data, but being able to extract data out and consider it systemically. The high frequency, low-level incidents may be considered “nothing events” one by one, however, in considering trending we may be able to detect widespread
deficiencies and vulnerabilities for the organisation.
Feedback/learning after the incident.
Do you have formalised, effective measures in place to ensure the learnings from incidents are disseminated to the workforce? The investigator and management team know all about the incident, but operators should receive briefings to ensure the learnings are understood and applied in their work areas. Overall, organisations need to focus not only on having incident investigation protocols and systems established but ensure they focus on analysing their effectiveness.
Jo De Landre is COO for Safety Wise, which is a diamond corporate SIA member. After 15 years with the Bureau of Air Safety Investigation (BASI), which became part of the multi-modal
Australian Transport Safety Bureau (ATSB), Jo started cofacilitating ICAM training with Safety Wise in 2001 as the principal human factors consultant. She was subsequently promoted
to the positions of executive general manager in 2005 then chief operating officer in 2017 of Safety Wise. Jo has been the Safety Wise Lead Investigator for many high-profile accidents, including multiple fatality investigations. She has a Bachelor’s Degree in Applied Psychology and a Graduate Diploma of Psychology, and has published papers in aviation, mining and police journals and publications.