“We cannot solve our problems with the same level of thinking that created them.” Albert Einstein
In Incident Investigations: A Guide for Employers, OSHA defines an incident as “a work-related event in which an injury or ill-health (regardless of severity) or fatality occurred, or could have occurred.” Incidents vary from large scale, such as the Deepwater Horizon disaster in 2010 that killed 11 people, to smaller scale, such as an employee slicing off the tip of his finger at a job site. While they are typically accidental, incidents may be planned – arson, sabotage, labor action, assault, or robbery are examples. While we can say that any incident is avoidable, in a perfect world, we would say all incidents are avoidable. However, as discussed in my previous blog on risk tolerance, zero risk is not a reality and where there is risk, there are bound to be incidents. While we can’t eliminate risk entirely, we can learn from our mistakes or the choices made by others, decreasing the likelihood of another incident occurring. This is where safety incident investigations play a fundamental role.
What is an incident investigation?
Does your company have a procedure in place to determine the root cause of an incident that results, or almost results, in a worker injury or illness? Or a procedure to prevent the injury or “near miss” from recurring? Some incident investigations are designed to answer questions like “Was a crime committed, and if so, by whom?”, “Were regulations violated?”, or “Is there contractual or tort liability?” A responsible employer demonstrates their company’s commitment to the safety and health of their workers by reacting quickly to an incident using a safety investigation procedure. While other investigations look backward, a safety investigation is focused on the future. “How do we keep this from happening again?”
It is, however, imperative that the investigation be done correctly. The investigator should be someone trained in incident reporting (OSHA Form 301) and, if no litigation or criminal investigation is anticipated, a person trained in accident analysis. If litigation or criminal investigation is anticipated, the company should proceed with the investigation as directed by an attorney. The investigation should never be conducted by the immediate supervisor or the injured employee. Investigations generally work best when managed by a team. A thorough and accurate investigation will help the employer to look beyond what happened and discover why it happened. This, in turn, helps the employer to correct any shortcomings that need to be addressed.
OSHA has suggested a four-step program for an effective incident investigation:
- Step 1. Preserve/Document the Scene
- Step 2. Collect Information
- Step 3. Determine Root Causes
- Step 4. Implement Corrective Actions
While one company’s investigation procedure will vary from another’s, this OSHA-suggested program provides an effective basis for investigation. Caution should be exercised, however, in determining a root cause. Incidents are rarely the fault of one person or event and setting out to place blame can compromise the question the investigation seeks to resolve: How do we prevent this from happening again?. This isn’t to say that assigning blame is never appropriate, only that assigning blame is not the objective and should only be done if it contributes to preventing a similar incident from happening again.
Fault vs. Blame
Our society has become fixated on assigning blame. However engrossed society is in placing blame, the one thing incident investigations shouldn’t do is pursue blame for every single incident. The goal of an investigation should never be focused on determining blame, or for that matter, seeking to place blame as a means of resolving an issue. Each incident is different and there isn’t always someone to be blamed. Again, incidents are rarely the result of a single error or failure. Nevertheless, while we do not want to seek to place blame, we do want to know how and why the incident occurred, and what actions led up to the incident. We want to know what is responsible, not who. We want to know the faults that led to the incident, the errors and failures. Knowing who made the error is only helpful if it helps to prevent a similar error in the future.
That being said, in some cases blame is appropriate. Sometimes the resolution for “why” turns out to truly be maliciousness and the responsible parties should be held accountable. Still, caution and tact are advised. An honest mistake is one we can learn from, but only when acknowledged. As soon as admitting to a mistake becomes punishable, we can only expect people to stop admitting to the mistakes and we lose an opportunity to learn.
We’ve probably all heard the proverb “one bad apple spoils the barrel.” Is this true on occasion? Sure! While one malicious employee, or “bad apple”, is plausible, the “bad apple” excuse is also an organization’s way of saying “Look, this isn’t our fault – what can you do about one bad apple in the bunch?” When an organization believes it is in a “bad apple” situation, it should seriously consider whether the incident was truly the result of a reckless or malicious individual, or was it a flawed system that initiated a chain of events? The problem the “bad apple” explanation is that the overall system and its regulatory construction get acquitted. The “bad apple” explanation hints that we needn’t worry about the system, just the one or more employees with ill intentions. Since the number of employees with ill intent is few, we might as well wait until something goes wrong again to step in. Therefore, the “bad apples” theory becomes an advocate for complacency and the likelihood of a similar event happening again is unchanged. The problem with the “bad apple” explanation is that the organization doesn’t know in advance which apples are going to go bad, yet the barrel is still full of apples.
Criminalization of Incidents
Some incidents–arson, sabotage, assault, or robbery—warrant criminal charges. What about the multiple casualty incidents where an intention to do harm never existed? Often times, an attempt to criminalize these types of incidents falls back on mid-level management. It doesn’t include the senior executives who pressure mid-level management with time and financial constraints, or even make the call themselves to take shortcuts when they are not directly involved in the process in question.
It may be convenient to blame someone in mid-level management, but they are not acting in a vacuum, so who is liable? Will imprisoning a supervisor solve the problem if he or she was simply making the best decision they could when faced with a set of deplorable choices? In situations such as these, perhaps time and resources are better spent on creating better choice, rather than defending against the potential of blame and litigation.
“Leave No Stone Unturned”
Albert Einstein said, “Condemnation without investigation is the height of ignorance.” While incident investigations weren’t specifically what he had in mind, the idea applies. Safety incident investigations are a safety tool, not a means of accusation. It’s imperative to be sure your investigation is thorough and the appropriate amount of time is allotted for its completion, and that the person doing the investigating is appropriately trained. Determining an accurate root cause is vital in preventing a reoccurrence and ensuring the safety of employees and the future success of the organization. It’s important to collect all the facts and build a credible case before allegations are made or litigation is sought if the “why” does, in fact, turn out to be a “who.” Otherwise, the current investigation—and future investigations—can be compromised. Cutting corners may reduce investigation costs and save time, but a poor or amateur investigation does more harm than good.