Why investigate when something goes wrong anyway?

Like most things we do in our lives, both in our work and outside of our work, we need to clearly understand why we do what we do. Those who know why they do what they do function at a higher level than those who simply know what they do and how they do it. Those who know why they do what they do get to live their passions. Those who know why they do what they do don’t consider their work ‘work’, it is their lives. This is just as true for an element of work such as a workplace incident investigation as it is for bigger questions like career and the effort we put into being authentic in our leadership. Those who know why they are investigating a workplace incident get the point that the process of doing the investigation is a learning experience each and every time and is also an opportunity to show authenticity as a leader. Those that just want to find out who did what and what controls to put in place to make sure that person doesn’t do it again tend to see investigations as something that must be endured, a chore, and something to be gotton through with as little pain as possible. It will be just another box to tick. This is a missed opportunity as this is the way NOT to learn from an incident.

We have a choice when we investigate a workplace incident – we can choose to learn or we can choose to blame. It is very difficult to do both. In order to learn from an incident, we need to have a growth mindset and be very curious about what elements conspired to create the incident: We need to seek to understand what part our leadership played; what aspects of our culture contributed; what systems, processes, environments et cetera played a part; we need to land on how all the interrelatedness of these elements set up a situation where things did not quite go as we planned them. To set up to do this, we need to do a few things:

1.    Spend time as an individual and as a leadership team (if you are part of one) exploring the ‘Why?’ of incident investigations

2.    Be curious, have a growth mindset, be keen to learn from the incident

3.    Establish an investigation team that has a good level of diversity (of thinking):

a.    Independent leader, 

b.    Independent investigation process facilitator,

c.     Subject matter experts, and

d.    Real people (Front line workers who really know how the work is normally done, not only how we think it is done)

4.    Give them the time and resources to do the investigation justice

5.    Use an established method such as Work-As-Written, Work-As-Normal, Work-As-Done based 5- Whys, or something more complicated if needed

6.    Trust the team to come up with the answers and encourage open and transparent discussions of incident drivers.

I want to share some of the drivers for these team member choices. 

Independent leader: The reason we have independence in the investigation leader is that you cannot have the fox looking after the hen house - you cannot mark your own homework. In order to get into the nitty gritty of a localised system, culture or leadership element that contributed to the incident, you need to have an appropriate level of independence in the leader. A manager from another department is usually sufficient for this role.

Independent investigation process facilitator: The job of the facilitator is the toughest in the team. They come armed with a proven process that when followed using a facilitation style, will maximise value-adding participation by the team members and getting to the nub of the issue. My advice is to develop a small number of facilitators and ensure they are supported, given feedback on their work and developed over time. They will help facilitate learning. They will also be able to tweak the investigation process to suit the incident. Most investigation methods are based on models and the facilitators need to understand them and then use them to help us get where we want to get to and not to get all pedantic on process. Avoid too much Newtonian cause and effect stuff for example. Let the process flow and keep it simple. The facilitator will help with all of this. 

Subject matter experts: Getting a couple of people at the top of their field really helps the investigation team understand the technical aspects of the specific work involved in the workplace incident. This greatly increases the team’s understanding of how the job needs to be done in a certain way and why.

Real people: Front line workers, whether nurses, doctors, engineers, maintainers, pilots, mechanics or operators, know how the real world works. Managers and most leaders do not. We think we do, but the way work is done (Work-As-Done) does not always equal the way we think it is done or the way our systems and process say it is done (Work-As-Written, or Work-As-Intended)

So, after we have the investigation team is all sorted, it is worth stopping and re-considering the team’s mindset. Does it have a growth mindset, where it is ready to learn, expand and grow? Or does it have a fixed mindset, focussed on what is broken and fixing it. The other mindset to consider is one of whether the team has a finite or an infinite mindset. By this, I mean whether we want to win the short-term game of preventing occurrence, or whether we want to play the longer-term game of taking advantage of the incident to help us learn what we can do to further build our approaches to getting it right into the longer-term future. This is the classic choice between the finite game and an infinite game scenario Simon Sinek talks about his new book The Infinite Game which came out in 2019 and is published by Penguin Business – well worth a read by the way.

So, in summary, think about how you think about investigations; think about why investigations are critical to learning.  Think about setting up the balance and diversity of thinking in the investigation team for success, and then maintain your curiosity and authentic leadership support for the process, aim to learn not to blame, strive to recognise the need to understand how we normally get it right (Work-As-Normal) in order to understand how we got it wrong (Work-As-Done) and generally use an unfortunate incident as an opportunity to display your authentic and caring leadership characteristics.

Further reading: Simon Sinek, Eric Hollnagel, Sidney Dekker, Ian Long