Many organisations struggle to yield meaningful outcomes from incident investigations. This paper will demonstrate that we can discover systemic issues by rethinking the ‘Why’ and ‘How’ of investigations, fostering genuine risk reduction. Key points:
1. Shift from ‘prevent recurrence’ to ‘learn and reduce risk’: conventional investigations focus narrowly on recurrence prevention, resulting in narrowly focused investigations with limited ability to identify and reduce organisational risk. Redirecting our objective to learning and improvement opens avenues for broader risk mitigation.
2. Understanding daily work for risk insights: recognise that work is not always completed in full compliance with procedures. Workers will adapt how they complete tasks influenced by the conditions and management systems that exist every day. Understanding the conditions and systems affecting everyday work is vital for uncovering systemic risks.
3. Unearth systemic issues through in-depth exploration: many investigations address surface concerns such as lack of training, incorrect procedures, equipment not being maintained, and missing overarching organisational risks. Systemic, organisation-wide risks are not identified. To discover these systemic issues and create shared learnings, investigators must question management systems, including resourcing, planning and risk management.
4. Design actions for safe failure: common actions like discipline and training fall short and do not reduce risk. Resilience emerges from well-designed controls. Incorporate planning, better resources, interlocks, and guarding to bridge the gap between task execution and risk.
5. Investigation Reports as a Business Case: Investigation reports should not simply state historical information regarding an incident. They are to facilitate decision-making and be presented as a business case to drive change.
Organisations can move beyond localised risk and ineffective administrative actions by changing investigation objectives and methods. They can facilitate learning, understand daily work intricacies, identify systemic issues, and enhance the capacity for safety, driving lasting risk reduction.