(43b) Do Not Investigate. Learn. Ask How!

Why investigate incidents? If your answer is to prevent the next one, you are on the wrong path because the same incident will never happen again. If your answer is to learn, then you are on the right path. This presentation shares our learnings from the past five years as we shifted our focus from investigating to learning. We are often asked “how do you do a good investigation”? The answer is relatively easy and straightforward. Start by changing your language from investigating to learning. We are not the police, after all, are we? Then, ask "how", not "why" and be mindful of hindsight bias. Talk to the people who were involved in the event - look at it from their perspective AND talk to the people who do similar work in a similar area - understand the context from their perspective. Conduct a safeguard analysis and ask three questions: What safeguards existed and worked? What safeguards did not work? What safeguards did not exist? Develop a good timeline of events that includes perspectives of all parties involved. It’s probably not as linear as you think! Accept the fact that there is more than one true story after an event. It is also important to keep in mind what NOT to do while we learn. For example, do not end your learning opportunities with the following: procedure not followed, work practice not followed, stop work authority is not used, hazard/risk not recognized. These are starting points for learnings and not the end points. If you end here, you really did not learn much from the event. This presentation will share two case studies where we applied this new thinking and how that shifted what - and how - we learned from the events, along with how our culture improved.