During my many years in safety, I’ve led dozens of incident investigations and, in general, enjoyed doing them. “Playing sleuth” appealed to my innate curiosity, and I felt confident that I was performing the task well. I have known many safety professionals to feel this same thrill of accomplishment; there is little question that well-conducted investigations add value by identifying system deficiencies and opportunities for improvement. OSHA’s statement that they “improve workplace morale and increase productivity by demonstrating an employer’s commitment to a safe and healthful workplace,” also rings true. However, there is little consensus regarding the appropriate goals, methodologies, and ownership (whether they are ideally conducted by safety staff or line management) of incident investigation. Even the terminology “investigation” leads to contention. Investigations are often used as tools of authority figures to displace blame. Many safety professionals, including myself, prefer less intimidating labels, such as “learning opportunities” or “incident assessments.” Regardless of disagreements over jargon, we should all at least manage to agree on what we hope to achieve by regularly performing these operations.
Inquire, Understand, Improve.
Often when something goes wrong, it is attributed to human error. As the saying goes, “To err is human.” People aren’t perfect, and therefore, mistakes will happen. When mistakes do occur, we need to look closer and try to understand why people made them and why our system/culture facilitated them without appropriate anticipation or mitigation of the consequences. Looking for human error apart from its systemic causes is superficial and generally counterproductive. Holding workers accountable is necessary in egregious cases, but if the factors that allowed for the “human error” are not improved, it is a recipe for recurrence.
Rather than a search for what went wrong with the goal of assigning blame, an incident investigation should be an opportunity to learn and improve. In the hope of discovering the root cause, do not stop at finding out what happened, but why it happened. Productive investigations leading to sustainable improvement are more than a hunt for “human error;” rather, they seek to establish understanding. That understanding can then be tapped to address system weaknesses, not only making similar incidents less likely but improving safety overall. This process includes answering why things didn’t go as planned and why those weaknesses weren’t identified and corrected previously. Additionally, an examination of the things that did go well is essential to build on those successes.
Three Common Barriers to Learning from Incident Review
Over decades of conducting organizational assessments, I have reviewed thousands of incident reports. Many exhibited at least one, if not more, of the following serious weaknesses.
- Confusing the proximate cause with more fundamental root causes.
An incident occurring immediately after a particular action or equipment malfunction does not make those situations the root cause. That assumption would be equivalent to assigning heart failure as the root cause of all fatalities. A more in-depth observation of any incident will almost always reveal interacting factors (e.g., production pressure, faulty procedures, etc.) that culminated in the operation’s failure. Identifying and correcting those precursors is necessary for avoiding recurrence and promoting sustainable improvement. Proximate causes are symptoms of more systemic problems.
2. Excluding management from the incident review process.
It is common practice for safety personnel to conduct incident reviews autonomously before handing off the results to the (understandably) defensive management. Unless the incident directly affected a member of the safety staff, it is not the responsibility of the safety staff problem to investigate or fix it. Management is both the party responsible and the one with the most to gain from the review findings, so why should they be idle bystanders? Safety representatives can train managers in investigation techniques and root cause identification, while participating in the investigation as subject matter experts, but leadership belongs to management. This may be a difficult transition for others, as it was for me, but it is ultimately the most productive path.
3. Blame, Shame, and Retrain.
No one wants to experience a serious accident or damaging incident. Even so, when the inevitable happens, incident investigation events are vital learning opportunities that should drive us to take a deeper look at how organizations deal with risk overall. We are obliged to learn from our mistakes, looking beyond the proximate causes of the systemic deficiencies that set up that failure. Incident reviews can be a wake-up call and remain one of the best sources for identifying and correcting deficiencies. Stopping the search at “human error” is the simplest way to squander that opportunity.
Corrective actions, even from well-conducted incident reviews, that include fixes such as “cautioned the operator to be more careful” or “retrain the operators” are indicative of a copout. These actions, as well as directives to develop more, bigger, and/or increasingly complex rules and procedures, are overused and counterproductive. They “check the box” for having taken action, but they avoid addressing the systemic issues that will result in the next “mistake.” Additionally, they can cost you the trust of your workers and make their jobs more difficult.
Mr. Loud’s over 40 years of safety experience includes 15 years with the Tennessee Valley Authority (TVA) where he served as the supervisor of Safety and Loss Control for a large commercial nuclear facility and later as manager of the corporate nuclear safety oversight body for all three of TVA’s nuclear sites. At Los Alamos National Laboratory he headed the independent assessment organization responsible for safety, health, environmental protection, and security oversight of all laboratory operations.
Mr. Loud is a regular presenter at national and international safety conferences. He is the author of numerous papers and articles. Mr. Loud is a Certified Safety Professional (CSP), and a retired Certified Hazardous Materials Manager (CHMM). He holds a BBA from the University of Memphis, an MS in Environmental Science from the University of Oklahoma, and an MPH in Occupational Health and Safety from the University of Tennessee.