Have you asked yourself those hard-to-answer, but necessary-to-answer-honestly questions?

If you are new to this blog today, then you really should read my archive. Those of you who have been regulars here know that I essentially (without actually specifically mentioning it) gave you homework over the weekend. The goal was to help you understand the heart and soul of incident investigation, which often goes by the wayside for political purposes if nothing else.

[Image courtesy of Flickr user Jan Tlk via a Creative Commons license]

[Image courtesy of Flickr user Jan Tlk via a Creative Commons license]

Last week, I began looking into a fascinating article by Fred Manuele in the May 2016 issue of Professional Safety magazine. Manuele’s work covers incident investigations in a workplace, and addresses perhaps the two more necessary but often more politically difficult questions to answer.

The Vital Safety Questions

We all know the questions that we often should answer completely when looking into an incident – who was involved, what happened, when did it happen and where did it happen. We can write copious, detailed notes and get good information from witnesses as to these fundamental questions, but  do these answers really address the incident and help us get what we need to prevent future incidents?

The two questions left off are the two that really should be what gets us to the real issues with an incident – how it happened, and why it happened. Manuele wrote a longish article looking deeper into what these questions address – which is, simply, causation. It is one thing to get the answers to the how and why questions; the next step is to understand the answers and convert them into actionable steps to help mitigate risk and hopefully prevent the same incident from happening again.

Therein lies the challenge, because there is a chance that the answers you might get may not be politically expedient in the workplace – you know, the chance that the how and why could point back to the company or to the safety officer and the deficiencies in the safety protocols.

Incident Causation

How and why tend to point to one key aspect of an incident – causation. Understanding what caused the incident to happen (and the unvarnished, apolitical causes, by the way) is the only true way to address the issues and undergo real risk-mitigation efforts.

Manuele pays particular attention to work by Erik Hollnagel and Sidney Dekker to discuss the issue of causation and how to actually look at it. In two separate works, Hollnagel and Dekker take the stance that incident investigations should not be about finding a single cause of incidents, because no such thing actually exists.

Both Hollnagel and Dekker agree that determining causation is not about a single cause, and to conduct an investigation with that goal in mind misses the ultimate point of the investigation. They both claim that there is a difference between finding the answers to the how and why questions, and an actual singular root cause of an incident.

A Unifying Message

Both Hollnagel and Dekker say that any investigative model that looks to get at a single root cause is inadequate to fully address the hows and whys of incidents. As Dekker wrote in 2006, “Cause is something we construct, not find. And how we construct depends on the accident model

[in which we believe.]”

There seems to be a growing chorus of people who are not of the root-cause camp anymore. There is a consensus now that root-cause analysis can be counterproductive, if not entirely unproductive. Next time, I will delve a little deeper into causation as Hollnagel and Dekker see it, and perhaps try to give some insight into how we should be looking at these important how and why questions when we investigate future incidents.