"I have analyzed over 1,800 incident investigation reports completed by supervisors or investigation teams, mostly for larger companies. On a scale of 10, with 10 being best, a composite score of 5.5 was given, and that could be a bit of a stretch.
"My findings were that causal factor determination was significantly deficient and that the gap between issued procedures on incident investigation and what actually takes place can be huge. Even in the best safety management systems, the quality of incident investigation can be unsatisfactory.
"I ran a Five Why exercise to determine why there was such a huge gap between issued procedures and what actually takes place. As the exercise proceeded, it became apparent that our incident investigation model is flawed.
"When supervisors are required to complete incident investigation reports, they are asked to write performance reviews on themselves and on the people to whom they report – all the way up to the board of directors. Also, at every level of management above the line supervisor, a normal aversion exists to being factually critical of their operations.
"Understandably, supervisors do not expound on their own shortcomings or of the shortcomings of the people to whom they report. Incident investigation systems are usually constructed so that the probability in favor of accurate causal factors being recorded in investigation reports is minimal. The likelihood is close to zero that a supervisor will write the following in an incident investigation report: 'This accident occurred in my area of supervision and I take full responsibility for it. I failed to . . . I should have done . . .'"
"What James Reason wrote in Human Error with respect to operators (first-line employees) and their relation to incident causation also applies somewhat to supervisors. Reason wrote: 'Rather than being the main instigator of an accident, operators tend to be the inheritors of system defects created by poor design, incorrect installation, faulty maintenance and bad management decisions. Their part is usually that of adding the final garnish to a lethal brew whose ingredients have already been long in the cooking'” (p. 173).
"Supervisors are one step above line employees. They also work in a 'lethal brew whose ingredients have already been long in the cooking.' They have little influence on the original design of operations and work systems and are hampered in so far as being able to have major changes made in them."How can you help? If you are aware of a system that improves incident investigation quality, please consider sharing that information with Fred. (Note that the content may become a part of an article to be submitted for publication consideration.) Fred is also seeking information from organizations that have instituted procedures whereby certain incidents are investigated by teams. He reports that among the reports he has reviewed, those completed by organized teams were better than those completed by supervisors. However, he notes that the literature on team incident investigations and results achieved is limited.
Send an e-mail with your information to professionalsafety@asse.org and it will be forwarded to Fred.
