A. J. Khan, Contributing Author, Riyadh, Saudi Arabia
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.