Nobody’s perfect. Despite all precautions taken, control measures implemented, hazards identified and reduced, risks mitigated, and a strong safety culture, your organization can still suffer an incident.
Even if you have an objective of zero incidents, there may be some on the way as you eventually achieve that goal.
When an incident occurs, as per your policies and processes you conduct a thorough investigation to get to the root cause(s) and prevent recurrence. The investigation includes an examination of the scene of the incident, interview of witnesses, the collection of data and evidence, checklists of questions to ask or items to verify, etc.
But even if you have a comprehensive incident investigation process, there still may be one key question that you’re forgetting to ask.
The Need for Deep Introspection
Let’s start with some background.
The Human Performance, Root Cause, and Trending (HPRCT) conference that took place last month featured presentations from Bob Nelms and Scott Griffith on developing high reliability organizations through human performance.
Nelms spoke about what he calls “The Blame Paradox”. The Blame Paradox is that we can find fault in performance either by looking at our own behavior or by looking at the behavior of others, but we can’t do both simultaneously. The result is that only a few people can see what is wrong with themselves, and so nothing changes.
According to Nelms, in order for organizations to be high performing and highly reliable, people need to address who they have become and what they have gotten used to doing. At the root of all physical and system problems are human problems.
In other words, this is the key question that you should ask yourself to address the human element in incident investigations:
What have we gotten used to getting away with, which didn’t result in consequences until now?
Another way to ask the question is: “How have we become complacent in our actions and thinking to result in an event?”
When an incident occurs, it’s not enough to address the physical and system aspects that contributed to the event, even though these are important elements. There must also be a deep introspection that looks at human performance without assigning blame.
System and Personal Factors
Sticking with the theme of introspection, Griffith agreed about the need to ask introspective questions. He said that too much trust in yourself and others can lead to complacency and a failure to perform checks of work, systems and procedures.
In addition to asking what it is about you and others that contributed to an event, you should also look specifically into the following that influence human performance:
- System Factors: Training, environmental distractions, equipment malfunction, etc.
- Personal Factors: Health issues, fatigue, stress, distractions, past experience, etc.
According to Griffith, organizations need to look at the intersection of system and personal factors for deeper introspection and understanding into why people take more risks.
In conclusion, to effectively investigate incidents and become a better organization, you need to be introspective and open to seeing your own failures. Asking yourself the key question mentioned in this post is a great start.
View the recording of our webinar with TapRooT® to learn how you can enable a human factors-based incident investigation lifecycle, and how the integration of Enablon and TapRooT® facilitates the tasks of incident investigators: