There has been some discussions and commentary in various online forums recently looking at the issue of “positive” incident investigations. Although there seems to be a variety of nuances in the description of positive investigations they focus on “what went right“.
Some of these investigation models have also incorporated a broader management technique of “appreciative enquiry“, which, as I understand it, came to prominence in the late 1980’s (see HERE for examples and information about appreciative enquiry).
The discussion about these frameworks describes the “what went right” philosophy as a positive view of investigations. It is a philosophy that does not focus on blame, but promotes discussion:
The benefit of that approach is that the conversation with witnesses is an entirely positive one. It is not about what could have happened. Not about the doom and gloom narrowly averted. Rather, it is about their heroic act, well designed process or lucky event that allowed us to avoid the adverse outcome. People love talking about positive things particularly if they had something to do with them. (https://www.linkedin.com/pulse/investigate-your-serious-near-misses-positive-way-michael-tooma?trk=prof-post)
In my view, when organisations are not mature enough to talk about issues in a non-judgmental way, without attribution of blame, the “what went right” enquiry may present a risk. It may be seen as a contrivance, with the facilitator spending a lot of their time saying things like “remember this is not about blame“.
In “mature” organisations the need to construct a system of enquiry to focus on the positive and avoid discussion of blame is largely redundant because the participants are aligned with and support the goals of the organisation. Their desire to support the goals of the organisation overrides any petty, personal concerns about individual praise or blame.
If you have ever been privileged enough to work with high-performance sporting teams or elite military forces, you will understand this idea.
A precondition of belonging to these groups is the willingness to say and hear things that support the group’s objectives without personal agendas or taking personal affront. The newest member of the team has a license to speak frankly about the performance of the most senior, and the most senior is expected to accept that conversation, not in the context of them personally, but in the context of the overall objectives of the team.
The extent to which organisations have to contrive a system whereby participants are corralled by a “what went right” narrative says a lot about the culture of an organisation and the “buy in” that people have to team objectives.
That is not to say that appreciative enquiry or investigating “what went right” does not have a place in organisations, nor that it could be an important building block along the way to developing something like an elite performing team. But as a word of caution, you should also understand some of the paradoxes involved.
The Safety Paradox supposes that any initiative done in the name of health and safety has the potential to both improve and damage health and safety in a workplace.
Having sat through appreciative enquiry “management brainstorming sessions” and incident investigations there is a strong sense of “flavour of the month” initiative as well as an even stronger sense of avoiding accountability. An overriding impression of a process delivered without context or explanation – why this and why now? The end product is a wall of butcher’s paper populated with sweeping motherhood statements and management speak, completely absent any meaningful desire to manage known problems.
The pendulum, it seemed, had swung too far the other way.
Again, that is not to say it is not an idea that should not be explored and applied. But it needs context. It needs explanation; it needs skilful facilitation, and it needs, perhaps most importantly, dedicated and meaningful follow-up with implementation. Otherwise? Well, we have all been in “those” types of sessions.
Another aspect of the “what went right” investigations is the requirement for something to have occurred. There needs to be an incident or near miss to trigger the enquiry.
A risk in the “what went right” enquiry (without more) is that it can contribute to the illusion of safety.
The illusion of safety is the gap between safety management as we imagine it in our organisation and what happens in practice. Incident investigations can be a powerful tool in exposing the illusion of safety because they have the potential to illustrate the disconnect between what we think happens and what is happening. By just focusing on “what went right“, particularly in near miss incidents, we may fuel the illusion of safety and create a narrative that our systems are working to protect us from these incidents – effectively papering over the cracks in the edifice.
While avoiding blame and promoting open discussion is important, so too is avoiding sugar-coating the situation. Again, balance, transparency and genuine enquiry ought to be the goal.
I would like to suggest something different – investigating work as it is performed; investigating when nothing happens.
An investigation framework that I find useful uses systems as opposed to causal analysis.
It supposes that organisations have systems and processes in place to prevent certain things from happening and tries to understand:
- What should have happened: how should these are systems and processes have been applied in a particular case to prevent the particular thing from happening; and
- What happened: how was the work performed in the particular case.
From there, we identify and try to explain the “gap” between what should have happened and what did happen.
This framework is not concerned with “causation“. All identified gaps are given equal attention and analysis, regardless of their potential causal relationship with the incident. They are all important because they all represent a potential systemic weakness in safety management which, given a different factual matrix, could be causal.
The attractiveness of this framework is that it can help you identify systemic weakness when nothing has happened.
A few years ago I was involved in an incident leading to the prosecution of a client following a working at heights incident. The incident and the various investigations that followed revealed the usual list of suspects:
- Training not followed;
- Procedures not followed;
- Risks not identified;
- Lack of supervision;
- Documentation not completed properly, and so on.
As part of working with that client, we applied the systems analysis framework to a range of other, similar high-risk work, including:
- Examples where the same task had been performed;
- Examples of different working at heights tasks; and
- Examples of other high-risk work tasks, including lifting operations and confined space entry.
In every case, the work had been performed “successfully“, without incident or near miss.
However, the analysis of the gap between how the work should have been performed and how it was performed demonstrated the same types of “failures” in the way that work was ordinarily performed as when the incident occurred.
In other words, even when work was “successful”, procedures were not followed, risks were not identified as well as they could have been, training was not complied with, documentation was not completed and so on.
The systemic weaknesses were not just present at the time of the incident. They were characteristic of the way work was performed in the days and months previously.
The incident was not a one-off departure from an otherwise “good” system – it was simply evidence of otherwise broader, systemic failures.
Moreover, this system analysis approach highlighted weaknesses hidden by the traditional safety metrics – injury rates, action items closed out, hazards reported, management site visits, etc. – all of which were “green“.
I have applied this method of review from time to time over the years where I have been able to convince clients of its value. On every occasion it brings to light the gap between the safety as imagined and safety in practice, lifting the veil on the illusion of safety.
In the Pike River Royal Commission, the Commission carefully examined Pike River’s system of incident investigation to understand if it “worked“. They reviewed 1083 incident investigations and did a detailed examination of 436 of them. Managers were subject to examination of their understanding of the investigation process, and ultimately the Commission found that “incidents were never properly investigated“.
You can see an example of the examination of management HERE.
Weakness in incident investigations, amongst other important systems elements, formed the basis of significant criticism of Pike River and its management:
Ultimately, the worth of a system depends on whether health and safety is taken seriously by everyone throughout an organisation; that it is accorded the attention that the Health and Safety in Employment Act 1992 demands. Problems in relation to risk assessment, incident investigation, information evaluation and reporting, among others, indicate to the commission that the health and safety management was not taken seriously enough at Pike.
What do your philosophy and implementation of incident investigations say about you?
My Safety Thoughts 