Incident investigation is a central role of safety professionals and a vital process for safety management in organisations. However, despite their importance, incident investigation processes often need to be more effective as learning tools across organisations. In this article, we will explore what an effective incident investigation process looks like, the science of human factors and the theory of just culture as they relate to incident management and investigation.
The Four Key Steps of an Incident Investigation Process
An effective incident investigation process involves four key steps: incident description, identification of causes, identification of changes to the organisation and work processes, and learning.
Step One: Incident Description.
After an unexpected event or a surprise related to safety in your organisation, it is crucial to understand what happened in as much detail as possible. The people involved in the incident know the most about the situation and should be considered your best resource. It is essential not just to look at the incident itself but also to explore everyday work related to the tasks involved comprehensively.
Step Two: Identification of Causes.
All incidents have multiple causes. There is no such thing as one root cause; if there were, we would have solved all safety problems by now. Identifying the variables that contributed to the circumstances that created the incident is essential. It is crucial to look deeply and non-judgmentally at the actions of all the people involved. Why did it make sense for them to make the decisions they did? Why did it make sense for them to do the work the way they did?
Step Three: Identification of Changes.
We then need to identify changes we want to make to how the organisation functions and how that work is done due to the incident. Recommended actions should always start with the outcome being sought and how it's different from what's currently happening in your organisation. This step is crucial as it allows validation that the identified actions will deliver the desired outcome.
Step Four: Learning.
Learning is sharing and institutionalising the knowledge gained and the decisions made during the incident investigation process. For understanding to occur, there needs to be a two-way open communication process between people in a way that challenges their thoughts and assumptions about work.
The Science of Human Factors and the Theory of Just Culture
Human factors are directly relevant to incident investigations and safety management more broadly. There are five exciting questions in human factors related to the incident investigation: Was it a mechanical failure or a human error? Why do safety systems fail? Don't errors exist? If you lose situational awareness, what replaces it? Why don't they follow the procedures?
The most critical aspect of your organisation that will determine the value and the learning you get from your incident investigation process is not your investigators' capability; it's your organisation's culture. More specifically, to what extent do you have a just culture? A just culture is an environment where learning and accountability are fairly balanced. However, the term just culture is often misused, misunderstood, and misrepresented. It relates to one of two extreme positions: either individuals should be disciplined if management followed the organisation's just culture process, or individuals should never be held accountable for their behaviours.
Neither of these two positions describes what a just culture is. A just culture lies between culpable and blameless. The real challenge in learning opportunities lies in understanding the complexity of the event and determining the level of accountability of individuals involved.
A just culture is not about protecting individuals from consequences but rather about understanding the systemic factors that contributed to the incident and addressing those to prevent similar incidents in the future. It is about creating a culture where individuals feel comfortable reporting incidents and accidents to stop them from happening in the future. A just culture also recognises that individuals can make mistakes, but those mistakes should not be used to punish or blame them but rather to learn from and improve the system.
Open and transparent communication is one of the critical components of a just culture. This means that individuals feel safe to report incidents and errors without fear of retaliation. It also means that the organisation is open and transparent about the incident investigation process, the findings, and the actions taken to prevent similar incidents.
Another key component of a just culture is accountability. This means that individuals and the organisation as a whole are held accountable for their actions and decisions. However, it also means that accountability is proportionate to the individual's level of involvement and responsibility. It is not about finding someone to blame but rather about understanding the factors that contributed to the incident and addressing them to prevent similar incidents.
In conclusion, incident investigation is a crucial process for safety management in organisations. However, it is often ineffective as a learning tool due to a need for more understanding of human factors and just culture. An effective incident investigation process involves four key steps: incident description, identification of causes, identification of changes to the organisation and work processes, and learning. The science of human factors and the theory of just culture play a crucial role in incident management and investigation. A just culture is an environment where learning and accountability are fairly balanced, and organisations must create such a culture to make incident investigation effective.
Do you need help to investigate incidents effectively in your organisation? Are you looking to create a culture of learning and accountability? Our Occupational Health and Safety consultancy services can help. We specialise in incident investigation, human factors, and just culture. Our team of experts can work with you to develop an effective incident investigation process, understand and address human factors, and create a just culture in your organisation. Contact us today to schedule a consultation and learn how we can help you improve your incident investigation process and create a safer workplace.
