2 Vital Incident Questions

Most investigations can get the four most basic questions answered in pretty short order – who was involved, where did it happen, when did it happen, and what are the details of the incident.

Oftentimes, two other questions are harder to answer, yet they could well be the most important ones to answer in order to have the correct response so future similar incidents won’t happen. These are the real contextual questions for every incident, and Fred Manuele wrote about them in a key article in the May 2016 issue of Professional Safety magazine.

The preface to this article has to do with what a couple of authors wrote were the perceived reality in safety. Manuele synopsized a couple of works from Erik Hollnagel and Sidney Dekker,  which seemed to address a certain aversion to causation of incidents. They combined in their commentaries to note six key observations:

1. The cause-effect description of any incident seems to be the least attractive option of several.
2. There is an inherent bias toward finding only the cause of an incident rather than also pursuing the explanation angle.
3. “Root cause” is pretty meaningless when it comes to incidents. Why?
4. Because a root cause is as existent as a unicorn at the base of a rainbow with a pot of gold.
5. The concept of “root cause” is just a way of explaining that investigation has stopped and there is no further inquiry being done.
6. Our personal perspectives on accidents are already formed when we investigate, and that tends to guide where we look for cause. Instead of letting the facts lead to a conclusion, we are concluding how an incident happened and then find the facts to fit that narrative.

From here, it seems pretty obvious what two questions need to be properly answered and are generally not, and there seems to be a pretty clear explanation as to the failure to find those answers, much less even pursue them.

Maybe it’s about preservation, but the truth is that these two most important questions, that are the hardest to find a truthful answer for, are questions that we really do ask as safety professionals, but we don’t really want to know the answer, so we work around the fringes. Why? We would hate to find that the incident could have been prevented and that at the end of the day, either the company or the safety officer personally was responsible for the shortcoming(s) that led to the incident.

No one wants to point the finger at himself or herself, or to actually go on record and say the company’s policies were to blame for an incident. Though the chances of that being the answer may be small, it’s enough to keep many of us from really opening up and honestly getting the real answer, because one possible answer might hurt too much.

What will be discussed in this new blog series is the breakdown of Manuele’s article, which looks at Hollnagel’s and Dekker’s observations about incident investigations and make us all take a good hard look in the mirror and answer these two questions which are really the most important in any investigation, and not only answer them honestly, but be able to understand those answers.

How did the incident happen? And why did it happen?

Yes, there may be compelling reasons why to avoid or sidestep those questions, but the honest answers must be obtained and understood before any real incident mitigation and risk controls could effectively be addressed  and implemented. Let’s look forward to the rest of Manuele’s article and understand what we need to understand in regards to the how’s and why’s of an incident before someone else gets hurt.