What Happened?

During the chaos that often follows a workplace injury, poor incident investigation can often leave us scratching our heads. To improve incident investigation, here are the ways to address the five most alarmingly common mistakes that people make under the pressure of the moment.

After a workplace injury occurs, we often scramble to understand things by doing a hasty investigation that often leads us to erroneous conclusions and flawed, even dangerous, assumptions about the circumstances in which a worker was injured. In our rush to understand the situation, we often lead ourselves to believe things that are convenient and easy to address when, in fact, they may be flat out wrong.

This might be acceptable were it not for the fact that the purpose of an incident investigation is to prevent injuries from recurring. Investigations that lead us to specious conclusions tend to lull us into a false sense of security. When we address the wrong issues we allow the true hazards to build and both the probability and severity of the hazard that caused the original injury tends to grow until another, perhaps more serious injury is all but certain to occur.

Before we can improve incident investigation we must address the most common reasons that we fail to do a sufficient job in our responses to injuries. There are five alarmingly common mistakes that people make in incident investigation:

(1) FOCUSING ON WHAT INSTEAD OF WHY
Western management styles tend to focus on ‘what happened’ instead of why things transpired in the way that they actually did. Instead asking why a worker made a mistake, we tend to answer the question ‘what happened?’ with ‘the worker committed an error’.

http://youtu.be/a4dwXGAk7Tg

Most manufacturers use repetitive ‘whys’ to solve operational process problems, but revert to a ‘what happened?’ mentality when investigating a safety issue. Understanding the factors that contributed to a process breakdown (which, let’s face it, that is what an injury really is because your process wasn’t designed to intentionally hurt someone) is essential to problem solving.

(2) SINGULARITY OF CAUSATION
Too often we look for a single root cause to which we can attribute to an injury, but injuries are seldom that simple. In most cases, injuries are not caused by a single factor, but rather by multiple, interrelated hazards that have interrelated causes and effects. In many cases, the proximate cause – the thing that happens and immediately results in an injury – is merely the weakest link in a chain of causation. In other words, it’s the straw that broke the camel’s back.

Problem solving professionals describe these kinds of problems as broad problems with a general structure, and yet those conducting incident investigations tend to use tools better suited for investigating a specific problem with a sudden structure. In the simplest terms, most organizations approach injuries as an event that came out of nowhere when, in many cases, the hazards involved have grown over time until the probability of injury was all but certain.

(3) PROVING AN ASSUMPTION
The first rule of problem solving is to forget what you think you already know. We seldom do this when investigating because we are often so focused on proving a hunch we might have that we ignore any compelling evidence that refutes our beliefs.