Not all supervisors lead investigations. For those who do, gathering facts and developing a list of recommendations that prevent reoccurrence is essential. To that end, we’ve highlighted several recommendations in this episode to help supervisors achieve a successful incident investigation outcome.
While Why-Tree analysis is a proven strategy, it's a tool with limitations. If, for example, you mistakenly identify contributing factors at the onset that are actually unrelated to the event, you'll follow a path unrelated to the circumstances involved. The consequences of this scenario, which occur more than we may realize, is experienced as recurrence of event. By solving for the wrong problem, we can't expect to identify the right solutions. As an example, several years ago, I led an investigation into an injury following a chainsaw kickback. The individual using the saw was attempting to bore cut a tree when the bar kicked back and into him. The investigating team quickly identified cutting technique used as a primary factor and wanted to pursue the path for follow-up recommendations. It wasn't until a coworker shared with me that the injured worker had filed down the raker height or cutting depth guides on the chain that the real picture began to take shape. While technique was a factor, it was the employee's decision to file down the cutting depth guides that ultimately led to his injury. As we later learned, the employee was very experienced with the chainsaw and knew he could cut more in less time with lower guide heights. The price to pay for the shortcut was high as it nearly cost him his life. Investigating incidents is about gathering facts and learning from them so that they can be avoided in the future. The key to achieving this outcome involves setting yourself up for success on the front end. To help do so, here are several recommendations for those that may be called upon to lead investigations:
1. Assemble the right team.
While some incident scenarios are easily mapped out and processed, others aren't. If the scenario is technical in nature or requires specialized knowledge or skills, include resources on a team that can fill those voids.
2. Start with the "what?"
Most investigation teams are assembled in response to an undesirable event where learning opportunities exist. Before plunging into the discovery process, it's critical to define exactly what happened. This forms the basis of the investigation and guides the team's actions.
3. Get clarity on the "how?"
In my experience, this is where most investigations get off the track in the early stages. As with the case described involving the chainsaw injury, technique used was believed to be the primary cause of injury. Had we not discovered equipment modification early on, someone else could have easily been injured using the same piece of equipment in the exact manner it was designed to be used. Once you know what happened, get clarity and alignment on exactly how it happened.
4. Exhaust the "why?"
With Why-Tree analysis, you continue to ask "why?" for each causal factor until all responses are exhausted. Why did the employee file down the raker guide? Why did he feel he needed to save time? Why did his supervisor not know? Why did coworkers not intervene? Why did equipment inspections not identify the modification? Run each causal factor to ground, and from there, develop a list of items for follow-up and corrective action.
5. Make follow-up items actionable.