Not all supervisors lead investigations. For those who do, gathering facts and developing a list of recommendations that prevent reoccurrence is essential. To that end, we’ve highlighted several recommendations in this episode to help supervisors achieve a successful incident investigation outcome.
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As Director of AEU LEAD, Joe White focuses on helping members transform operational goals into actionable plans through a structured change management process. Prior to joining AEU, Joe was a senior consultant for E.I. DuPont’s consulting division, DuPont Sustainable Solutions (DSS). He joined DSS in 2011 to develop the next generation of safety practices using extensive research in behavioral sciences he’s compiled over a period of nearly two decades. His efforts resulted in the development of The Risk Factor, which is now the flagship instructor-led offering for the consulting division. Combined, Joe has 26 years of operational safety experience, the majority of which was with DuPont. Joe has been published in Occupational Health & Safety Magazine for his prominent work in safety relative to behavioral and neurosciences and is an event speaker at many leading industry conferences including National Safety Council (NSC) Congress and Expos, American Wind Energy Association (AWEA), and National Maritime Safety Association (NMSA). Joe is a graduate of Virginia Commonwealth University and has a B.S., in Safety and Risk Administration.
Where you can find Joe
Supervisor Skills: Secrets of Success is a production of AEU LEAD, a division of The American Equity Underwriters, Inc. With 60 years of combined industry experience, our supervisor training program gives mid-level managers in the maritime industry the skills needed to influence employees, customers, and peers. This increases employee engagement, reduces turnover and rework, and ultimately results in higher profits for their companies.
When it comes to incident investigations, the wrong path is most often revealed by recurrence of event. In today's discussion, we're talking about the ingredients of an effective investigation process. Stay with us.
Hello and thank you for joining us. My name is Joe White, and I'm the host of Supervisor Skills: Secrets of Success. The SOS Podcast series is produced to create ongoing development opportunities for mid and frontline managers. With each episode, we take on topics of interest and share insights and perspectives for the benefit of our listeners. In today's SOS short episode, we're talking about incident investigations. More specifically, we're talking about Why-Tree analysis to determine root causation. While not all supervisors lead investigations, some do, and most are at least involved in them because of their technical knowledge and familiarity with the scope of work. It's my sincere hope that you'll find some value from our discussion today. Chances are, if you've been around industrial or service-related industries for any period of time, you've participated in an incident investigation at one point or another. While there are several common methods to determine causation, one of the more common techniques is referred to as Why-Tree analysis. In practice, it involves defining the incident event and listing possible causes for it. The Why-Tree method involves a questioning technique involving its namesake. For each listed calls, the investigation team continues to ask "why?" until root causal factors take shape. Once they do, the team is then able to put into motion countermeasures to prevent recurrence using the circumstances involved as a guide of sorts.
While Why-Tree analysis is a proven strategy, it's a tool with limitations. If, for example, you mistakenly identify contributing factors at the onset that are actually unrelated to the event, you'll follow a path unrelated to the circumstances involved. The consequences of this scenario, which occur more than we may realize, is experienced as recurrence of event. By solving for the wrong problem, we can't expect to identify the right solutions. As an example, several years ago, I led an investigation into an injury following a chainsaw kickback. The individual using the saw was attempting to bore cut a tree when the bar kicked back and into him. The investigating team quickly identified cutting technique used as a primary factor and wanted to pursue the path for follow-up recommendations. It wasn't until a coworker shared with me that the injured worker had filed down the raker height or cutting depth guides on the chain that the real picture began to take shape. While technique was a factor, it was the employee's decision to file down the cutting depth guides that ultimately led to his injury. As we later learned, the employee was very experienced with the chainsaw and knew he could cut more in less time with lower guide heights. The price to pay for the shortcut was high as it nearly cost him his life. Investigating incidents is about gathering facts and learning from them so that they can be avoided in the future. The key to achieving this outcome involves setting yourself up for success on the front end. To help do so, here are several recommendations for those that may be called upon to lead investigations:
1. Assemble the right team.
While some incident scenarios are easily mapped out and processed, others aren't. If the scenario is technical in nature or requires specialized knowledge or skills, include resources on a team that can fill those voids.
2. Start with the "what?"
Most investigation teams are assembled in response to an undesirable event where learning opportunities exist. Before plunging into the discovery process, it's critical to define exactly what happened. This forms the basis of the investigation and guides the team's actions.
3. Get clarity on the "how?"
In my experience, this is where most investigations get off the track in the early stages. As with the case described involving the chainsaw injury, technique used was believed to be the primary cause of injury. Had we not discovered equipment modification early on, someone else could have easily been injured using the same piece of equipment in the exact manner it was designed to be used. Once you know what happened, get clarity and alignment on exactly how it happened.
4. Exhaust the "why?"
With Why-Tree analysis, you continue to ask "why?" for each causal factor until all responses are exhausted. Why did the employee file down the raker guide? Why did he feel he needed to save time? Why did his supervisor not know? Why did coworkers not intervene? Why did equipment inspections not identify the modification? Run each causal factor to ground, and from there, develop a list of items for follow-up and corrective action.
5. Make follow-up items actionable.
Follow-up items are the fruits of labor resulting from an investigation. Corrective action should be assigned to an individual identifying exactly what must be done by when. Equally as important, task must be tracked and periodically reviewed to make certain they're being completed as assigned and as scheduled. Those that do this well, make completion of open action items an expectation impacting job performance. And for some, bonuses.
Incident investigations are important for a variety of reasons. When properly run, they help prevent recurrence of events and ultimately prevent unnecessary losses. For those involved, it's important to follow a structured process and to draw conclusions based on facts. The key to success in many instances involves understanding not only what happened, but how it happened. With this information in hand, teams are far more likely to have successful outcomes, providing recommendations based on the actual circumstances involved.
Thank you for joining us. I hope this information will help you grow and improve as a supervisor. We look forward to sharing additional podcasts with you in the months ahead and welcome any suggestions you might have for topics you would like to see us cover. We're always looking for guests and enjoy sharing insights and success stories from the field.
If that's something you would like to be a part of, just let us know. The SOS Podcast series is brought to you by AEU LEAD, a consultancy dedicated to the needs of mid and frontline managers. We value and appreciate any feedback and would encourage you to review and rate your experience with the show wherever you access your podcast. For additional information about AEU LEAD or to follow us on social media, please use the links in the show notes accompanying this episode. That's it for now. Stay safe, and thanks for listening.