Are incident classifications driving poor investigation outcomes?

There was an amazing amount of response with the vast majority of comments claiming this was a significant Incident or similar.

Recently I posted on LinkedIn an article providing very limited details of an event
where a haul truck has effectively run over a light vehicle. Based on the information provided in the article and the assumption that the “The fitter works alone and no one else was present at the time of the incident”, I asked how organisations would classify this incident.

There was an amazing amount of response with the vast majority of comments
claiming this was a significant Incident or similar. This seemed to be based on the assumption that someone may have been killed. If the fitter worked alone, and no one else was present at the time of the incident, I am unsure how this conclusion has been reached.

Regardless of how this event may be classified, the context surrounding the event, and how related tasks are normally completed, is clearly something the organisation should be invested in learning from.

Thoughts

I posted this question as I have seen organisations struggle with the classification of incidents. Most organisations I have worked with, utilise a risk matrix-based approach to assess actual and potential consequence, which then determines the type and scope of the subsequent investigation. This well-intentioned approach is taken to provide consistency of investigation level and ensure events with higher risk or outcomes are appropriately investigated.

Increasingly I have seen this approach result in adverse consequences; including over classification, poor investigation outcomes, unnecessary investigations and unsustainable workloads for those responsible for facilitating the investigation. In depth investigations, such as ICAM©, TapRooT©, root cause analysis, etc., take enormous resources, capacity and capability to complete with any level of thoroughness.

Understanding

Firstly, there seems to be a poor understanding and application of this approach. The actual outcome is usually easily understood; however, many are having trouble with assessing potential outcome. The main issues are that the link between what happened and what ‘might’ happen becomes tenuous and beyond credibility.

Way too many ’what ifs’ are applied. In my post I asked to assume that no one else was involved or exposed, yet many comments have placed a person at risk. Potential risks must be seen to be credible. To do this, an understanding of how the related task is normally completed is required.

This misapplication of the approach results in too many events being classified as high potential and requiring an in-depth investigation.

Injury driving all investigation levels

The second major issue I have seen is the link between injury outcomes and investigation levels. A common example is when an organisation’s investigation procedure details that a restricted workplace injury, or medically treated injury, require an ICAM© or TapRoot© investigation. Now, I am not saying that these events do not warrant an investigation; there should be some form of investigation, however, the outcome needs to be worthy of the investment.

Injury classifications by their nature are too simple to capture the true complexity, context and potential of the injury itself. Minor injuries are subsequently classified the same as a serious injury. E.g. The investigation methodology required for an injury requiring one or two stitches is normally the same as that for an incident for a worker who’s lost a limb. Exacerbating the issue, this depth of investigation is then required for minor restricted injuries such as rolled ankles.

Resourcing

This black and white adherence to this approach has, for some organisations, resulted in too many in-depth investigations. Organisations either rely on operations to investigate the events or fall back on to a dedicated safety resource. When operations are forced to ‘fit’ the investigation into their normal workload, they are seldom allocated sufficient time and assistance to truly identify systemic organisational issues. Outcomes are severely affected by the limited time allowed to develop true understanding of the context of the event.

Likewise, when investigations are the responsibility of the safety resource, they must find the time in their normal workload to undertake the investigation. They are rarely provided additional resources and often juggle several investigations at once. While most staff are likely adept in the chosen methodology, they simply do not have enough resources to complete a thorough investigation.

Final Thought

Immediately after an event, we often don’t possess all the information needed to make an informed decision. I have recently started challenging my clients to not react immediately when they hear of an event which may be high potential with the usual cry for a high level investigation. Instead, let’s take some time, not be constricted by a pre-formatted one size fits all framework, and utilise a diverse range of learning methodologies to understand how an event occurred during normal work.

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