What Were You Thinking? A Different Approach to Investigate Incidents

We live and interpret the world through an invisible lens shaped by our personal history and social context. Our own personal frames. There is nothing inherently wrong with seeing the world through our own frames and we all do it. The problem is when we accept our frames as absolute reality rather than a subjective view of reality.

This is what psychologist call naive realism. The view that we:

  • see the world objectively and without bias,
  • expect others will come to the same conclusion, provided they are exposed to the same information and interpret it in a rational way, and
  • assume that those who do not share the same view are either uninformed, ignorant, irrational, or biased.

Pretty simple, but yep, that’s me. Actually that’s each of us. While it is easy to see how crazy this view is, we live it all the time. So what does this have to do with safety?

Years ago, when all employees worked doing the exact same task – day in and day out, there was little opportunity or need for them to think about anything. In todays ever-changing workplace employees are expected to think and make decisions all the time.

Employees make decisions at work based on how the day unfolds before them. The input for their decisions comes from different directions including upper management, customers, immediate supervisors, co-workers, and even their families. Our frames are influenced by the social context so the company stock, or pending lay-offs, the mood of an immediate supervisor, peer-pressure from co-workers, and family illness can all affect our frames and subsequent decisions.

The CEO of your organization is just as vulnerable to his or her own framing in decision making as the line employee, so in that regard everyone is equal.

In addition, employees may have multiple and conflicting goals. There might be an expectation to perform the job strictly by the rules and yet employees might be driven by a clear, but unspoken expectation around production results. Those two goals might be vying for top priority and mental attention. Add to that the requirement for performing safely and a call from the daycare informing them their child is sick. All of these goals might influence how decisions are made and not necessarily equally.

Depending on the outcome of each decision, the difference between being a hero or a villain sometimes becomes a fine line. If an incident occurs the employee might be punished, if risky behaviors occur and a major production goal is met, they may be rewarded.

In his book Pre-Accident Investigations, Todd Conklin describes a scenario where a maintenance worker for a carnival ride company is faced with making a decision of shutting down or continue operating a ride that is making an unusual sound. The decision has to be made on a Friday before the biggest weekend of the carnival and shutting it down and taking it apart would be a two-day job. If he shuts it down Friday and discovers a major problem he is a hero, if he shuts it down and the noise is a minor problem there will be hell to pay at the main office. If, on the other hand he decides not to shut it down and people are injured or killed, the carnival could go out of business. That’s a lot of pressure for a man who turns a wrench.

While most workers in many companies may not face this level of decision-making, they are often confronted with conflicted goals. Understanding what was going through the employee’s head when the scenario unfolds at the time of the decision is critical.

Finding out what was taking place in the employee’s mind at the time of any incident may be a challenge, but is extremely important if the organization is going to learn and grow. First the employee must be comfortable speaking without fear of punishment, or they will not speak, and critical organizational knowledge will be lost. And the punishment doesn’t have to be major. Subtle innuendos by management might be enough for an emotionally intelligent person to understand that speaking up is a mistake. Management’s frame may be that employees should have known what to do and as a result may send the implicit message that the employee did something wrong – even though every other employee might have done the same thing given similar circumstances.

Once the underlying cause is determined the real learning takes place. The most important thing to understand is the fault is always with the organization or, management. But wait, what if, as I heard one manager say, we have stupid employees? Well…. who hired those employees? And what management system is missing or flawed that should have screened these folks out?

Or maybe there is the belief that employees didn’t do what they were told. Look at what they are being told, and not just verbally after the incident or during new employee training. Communication comes in many forms. The real learning takes place on the shop floor. So what messages are employees trying to decipher in their decision making process? Do these need to be clarified and communicated to everyone? Remember just because one employee had the incident, doesn’t mean there are not a number of employees facing the same issues. Some folks are just more skilled at dodging the bullet.

The recent bridge collapse in Miami, Florida and the ongoing investigation got us thinking about the need to develop a better approach to learn and prevent future catastrophic incidents. Doing so requires changing how incident investigations are approached. The benefit for all is significant.

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