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May 23, 2019

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Incident investigation

‘Investigation – Good Medicine’

We can be fairly confident in saying that virtually nothing can be achieved without investigation. We investigate from our first steps and continue through the rest of our lives. In our professional life, investigation is part of planning, design, risk assessment and almost everything else. It is therefore unfortunate when companies think that investigation is just a health and safety methodology only to be used when things go wrong.

David Ramsay

David K Ramsay, Group Managing Director, Kelvin TOP-SET

“We expect our doctors, opticians, dentists and even our car repair garage technicians to have diagnostic skills, so why wouldn’t we expect this of all staff within their area of expertise?

“Looking at this from a professional perspective, hopefully it can be seen that investigation is a powerful business tool, and that the skills acquired on an incident investigation course can have a much wider application.

“Over at least thirty years, we have developed a practical and easy to use methodology based on real experience from problems in small and medium-sized companies to some of the biggest failures and incidents imaginable, in everywhere from the offshore oil industry, to nuclear and aerospace industries. Therefore, we do understand that when incidents occur, particularly when safety has been compromised, there is a need to investigate to prevent recurrence. However, a professional investigation methodology enables the organisation to gain information from every part of the company and hence have the knowledge to make positive changes that will improve both performance and safety.

“Senior managers in all companies talk about their commitment to safety, but this has to be more than fine words because the alternatives can be unthinkable, including:

  • Loss of life, injury
  • Financial loss, depressed share value
  • Loss of company reputation, negative press or
  • Prosecution of directors.

“However, these are negative outcomes – ‘Bad Medicine’. By looking at investigation as ‘Good Medicine’, companies can identify what they are good at; what they can do even better. One of our clients trained 150 people to be investigators. Clearly, they didn’t need this many trained investigators, maybe just five or six, but what it did do was raise their knowledge level about the causes of incidents and failures, and hence operational safety levels. This approach can be related to and be part of other safety initiatives such Risk Assessment, BowTie HAZID, HAZOP, Front-End Engineering and Six Sigma.

“There is a huge misunderstanding about Root Causes across all industries. So often we are asked to train people only in Root Cause Analysis, and while we can do this, and even have a specific e-learning programme on it, the point is frequently missed. There has to first be a definition of the problem, then an investigation of the facts, before proceeding to analysis. Surprisingly frequently, we come across the real problem which is not thinking about the problem first. In one extreme case, an organisation that we worked for had lost £500 million (yes you read that correctly, half a billion sterling) because they hadn’t defined the problem or investigated what they really needed to. It was a total failure of ‘Front-End Thinking’.

“I appreciate that the audience for this article is probably made up of safety professionals, but the approach is the same whatever our discipline; it is about gaining information that can help us to improve our processes and hence safety. As one director of a company in an extremely high-risk industry told me, where they’d had fatalities in the past, ‘You can never take your foot off the gas, because if you do, it all very quickly starts to go wrong’.”

Causes of incidents

accident investigation“It may seem an oversimplification but virtually all incidents are caused by two things:

  • Change and
  • Decisions that people make (or don’t make).

“You may see this as controversial but try it for yourself. If things are going along fine, nothing happens, but if it does happen, there has to have been something different, there has to have been change. Then when we dig deeply, we find that, usually, well-intentioned people are involved in an error, maybe of design, bypassing a control, or failing to foresee consequences of an action. This is by no means finger pointing, it’s just a reality; people have to be at the heart of everything. So, hopefully, we can see that investigation can be good medicine, helping people to avoid having incidents. We talk a lot about preventing recurrence, but how much better is it if we prevent things going wrong in the first place?

“Many years ago, I coined the term ‘Organisational Rust’. Real rust, for want of a better term, is the slow degradation of mild steel over time. So it is in all of our organisations; small things, even tiny changes, often unnoticed, are going on all the time and, sometimes, building up to a point where they all come together and there is a major incident. Take time to look over the reports of any major incident in the public domain and you’ll find that there were a whole series of ‘minor’ failures that contributed to the final disaster.

“Taking the ‘Good Medicine’ approach is akin to having a healthy lifestyle and maybe also regular health screening. This is good management; being in touch with what is really going on, talking to all staff, and keeping people informed.

“Looking over decades of incident investigations, there is a surprising commonality in the failures and causes that we have seen, and they almost all have a major element of communications at their heart. From our own personal lives, we know that poor communication causes so many problems, and we are all guilty of this. So, why would it be any different at work where things are usually more complex?

“Effective risk assessments that cover all of the possibilities require creative thinking, teamwork and excellent communications and professional investigation.

“The question is not why would you train people as investigators, but rather why wouldn’t you?”


Webinar: Benefits of adopting an incident investigation methodology

A look at the key factors in applying a professional investigation methodology. Your chance to listen back, on demend, to SHP’s interview with David Ramsay.

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shaun stephenson
shaun stephenson
1 year ago

David K Ramsay totally looks like Mike Eurhmantraut from Breaking Bad!