Accident investigations are to a safety manager
as a stethoscope is to a doctor. These methodic, non-intrusive tools support a
quick observation of system, deriving a conclusion with a quality that is
proportional to the competence of the user. In the case of an investigation, what
is different is the “approval committee” which has the authority to dissect the
outcome, counter the narrative, challenge the status quo and, in all fairness,
accept its own “management failure.”
Before delving further into the subject, the
basics must be reviewed. According to Rasmussen,1 accidents are
caused by a loss of control of physical processes that can injure people and/or
damage property and the environment. Management is interested in investigating
an accident, primarily to prevent a recurrence, satisfy legal requirements and
review existing barriers for further improvement leading to enhanced operational
efficiency.2,3 However, not all investigations achieve the objective
entirely.
Ferry highlights the criteria related to the usefulness
of investigations.4 A successful investigation process should be (FIG. 1):
This article is meant to provide guidance to senior
managers and technical leaders who are “approvers” of investigation reports but
lack the time (and prioritization) to go in-depth to find the real cause of
incidents. While it is wishful to think that all investigations are conducted
thoroughly, statistics have proven otherwise. Tell-tale signs that an
investigation system is not living up to its true potential include:
The many factors that contribute to these symptoms can be summed up for easy understanding (FIG. 2) as:
The role of leadership is crucial in terms of
managing safety and staff motivation, especially during budget cuts and
resource limitations. Any corporate push of “doing more with less” should be
taken with a pinch of salt, since “quality never comes cheap.” Leaders must be
aware that every action has an equal and opposite reaction—they might not hear this
from direct reports, but business and safety KPIs will definitely provide
strong indications of success or failure.
ACHIEVING
BEST RESULTS
Maintaining a robust incident investigation
system under such constraints is a challenge that leadership must face and
conquer. Experience has proven that the best results are achieved with the steps
detailed here.
Honest
interaction with impacted employees. Leaders must meet the impacted unit’s operators
at all levels, which can help them develop their own version of accident
causation. Leaders must listen intently to employees’ feedback and their
proposed solutions around any issues. Leaders should actively try to resist
providing answers, but rather generate insights from the team’s feedback. They
should not become “emotionally attached” to a certain contributing or root
cause. There is no harm in tossing questions to the investigation team for
their active debate and assessment, and employees appreciate personal feedback
of their raised concerns and a public appreciation of good work.
Empowering
the team.
This is easier said than done, but the more empowered the team, the more agile
it becomes. Decisions do not have to be escalated needlessly, leaving leaders free
to focus on strategic tasks while functional leaders can manage the mundane.
Most empowered teams demonstrate the following traits:
Weekly
updates from the investigation team. A short update about an investigation’s
progress, the major issues being faced and any support requested from
management can make all the difference between an excellent outcome and one
that merely checks the box. Leadership must communicate their openness to
listening to uncomfortable truths to successfully avoid issues in the long
term, rather than a rosy lie leading to an embarrassing short-term outcome.
Audit
the auditor.
Insightful, open-ended questions to the investigation team will determine the
depth to which the investigation team will reach and ascertain root causes.
These questions can include:
Drive
the investigation’s quality by challenging the preliminary assessment report. A best practice is to
invite relevant professionals from other divisions/assets who can assist in
reviewing the preliminary report with a cold eye. The human mind is prone to
many biases, so it is always beneficial to calibrate against a competent
resource that has no stake in the outcome. The wealth of information expected
from such an intervention includes knowledge sharing on missing barriers,
insights on failed barriers and best practices around the subject matter.
Encourage active investigation of recovery measures, in addition to preventive
and mitigative barrier failures, thereby driving operational resilience.
If
serious about safety, be authentic in accountability. Management’s focus
should be to improve the process and not incite fear with disciplinary actions.
Accountability must be conducted with the utmost responsibility. Best results
are achieved when accountability is:
Short-term impacts (e.g., verbal/written
warning, safety gift deduction/presenting incident to shifts, time off from the
core job while at the worksite) are preferred over long-term impacts (e.g., yearly
appraisals, bonuses, career progression). The purpose is to drive behavioral
improvements, not to drive the team member away. Remember, we are interested in
keeping both the lesson and the person who learned it best within the
organization.
Push
your team to delve deeper and observe better. Some investigations are complex due to
process design, unknown variables, network interconnections and a lack of
awareness about certain mechanisms. Rather than closing the investigation
within its stipulated time:
The craft
of preparing an action plan. While many professionals place a priority on
determining root cause(s), it is the actions generated as a result that can
mark the difference between success and failure. While reviewing the action
plan:
Lead,
follow or get out of the way. The management team should initiate a Q&A
session with the investigation team and impacted unit personnel. Everyone
should be given a chance to contribute. Once the report is approved, any
question on the report’s credibility must be addressed.
View the
investigation report as both a door to the past and a window to the future. While conducting the
investigation, the team must ensure that relevant data, documentation, distributed
control system (DCS) trends, logs, records, procedure/report excerpts, interview
log, FTA/tripod beta tree, minutes of meetings, etc., are properly archived. Future
colleagues and teams will benefit from this hard work while investigating a
similar incident in future.
Integrate
the investigation system with an effective lesson-learned system. Major investigations
must be embedded in various platforms to maximize lessons learned. Best
practices include developing a one-page flyer with every investigation to be
shared to all employees in a safety meeting. A learning from incident (LFI)
committee should review various incidents and develop proactive action plans to
supplement existing controls across assets/divisions/businesses. Operations and
maintenance personnel should incorporate important lessons learned in their
work procedures and instruction manuals. An online LFI database and hard files
are kept for new employees, turnarounds (TARs) and safety trainings. HP
LITERATURE CITED
AAMISH J. KHAN is an Operational Safety Consultant who has been supporting various renowned companies in the oil and gas, petrochemical and utilities sectors in their safety culture enhancement journeys for two decades. He has a multifaceted exposure to operations leadership, occupational safety, process safety management (PSM), integrity assurance and audit, enabling him to identify, analyze and treat risk effectively throughout an asset’s lifecycle. He is now involved in co-authoring the Center for Chemical Process Safety (CCPS) Safe Work Practices guidelines, with the objective of enhancing the sharing of lessons learned across the global industry and softening the safety impact on workers' lives. Khan is a graduate chemical engineer and holds an MS degree in enterprise risk management from Boston University in the U.S.