There are many ways to complete an incident investigation. Some experienced managers can do it just by asking open-ended questions with appropriately selected interrogative questions. Lots of people love the “5 Whys.” I like the Ishikawa Diagram, which is very easy to use and great for brainstorming and teamwork. And there are the fun ones that may involve formal logic gates and pocket protectors.
Whatever route your prefer (or have to follow, depending on the gravity of the incident), the goal is always to identify causal factors behind the incident and then prescribe corrective actions to address them.
Regardless of the investigation technique you use, the findings, conclusions, and preventative measures all depend on the facts derived from the investigation. So, here are six ideas that will help you squeeze out every last drop of factual information from your investigations.
1. Focus on the Facts, Not the Person
A proper investigation is aimed at identifying the root cause of the issue through fact finding, not fault finding.
Avoid personalizing the incident. The employee is one part of it, but not the embodiment of the incident itself.
When locating the cause and issuing corrective instruction, focus on the specific actions, not the thought processes behind them. Though judgment and attitude have likely played a role, focusing on them can make those involved feel defensive, and many people are more helpful when they feel they're not being judged. Facts and actions, on the other hand, are impersonal. Focus on them and you'll see better results.
It's also important to remember that management oversight and deficiencies frequently play a part in incidents, even when they happen far away from the office, on the factory floor or the construction site. Sometimes, the employee is no more responsible than the management system – the very same management system the investigator is a part of. Focusing on the person instead of the facts makes it easy to overlook this and might cause you to miss some important root causes of the incident.
2. Separate the Incident Investigation from a Disciplinary Investigation
Always remember that the incident investigation is about gathering data, drawing conclusions, and determining corrective actions. One of those corrective actions might be disciplinary measures, but if those measures are required they should only be doled out after the investigation.
Now, there are some exceptions. If the scenario is grave enough, it might be important to remove the employee from duty during the investigation for liability purposes.
Don't forget to communicate this fact to the employees involved. They should be told that the purpose of the investigation is not to issue discipline but to prevent future incidents.
3. Avoid Distressing Interview Environments
In theory, the best place to interview a witness is the incident site. That way, they can point out where certain events took place and even demonstrate the actions that led to the incident. This might not be feasible in every situation, especially with vehicle incidents, but it is the reason why some people choose to conduct their interviews in these locations.
In reality, the best place to interview a witness is a neutral location, such as a conference room. This takes the emotion out of the interview, especially if some ghastly event has taken place.
Note, however, that an administrator's office might put the interviewee on guard.
4. Optimize Your Verbalizing
You're going to have to do a lot of talking during an investigation, so make sure you're saying the right things.
Don't talk down to the person or lecture them. Avoid negative comments, and don't reprimand or embarrass them.
Don't debate them, either! As an investigator, you must always remain calm and neutral.
Avoid comments about the person themselves. If it appears they were driving too fast, address the velocity, not the perceived foolishness that led to it. Asking "What were you thinking?" or commenting "That was really stupid!" have no utility or possible benefits. They will just result in an angry, defensive interviewee who is unwilling to share more information.
Be sure to ask some open-ended questions. Interrogatives (when, why, what, where, and how questions) are a useful way to expand the discussion and draw out more information. It's a good idea to respond to the interviewee's answers by repeating what was said for confirmation and to show that you were listening. But avoid repeating their questions; you could inadvertently alter their intent in asking the question and create confusion.
Positive leading questions can also build trust and reduce defensiveness. For example, asking "What do you think its the best safety practice with machine guarding?" implies that they practice safety to some degree. Even if that may not be the case, the positive framing of the question gives the interviewee space to open up and divulge information more freely.
Likewise, while discussing the actions that took place and the facts of the situation, be sure to acknowledge the person's positive skill and their knowledge. People like to be propped!
Finally, avoid providing vague feedback. If the person handled the incident scene very well, telling them "Good job!" is well-intentioned but ultimately useless. Instead, point out how excellent it was that they checked on the safety of the passengers quickly, called the emergency responders ASAP, and set up road cones for drivers to see. The same goes for events that could have gone better – make your feedback specific.
5. Optimize Your Non-Verbalizing
As I said, you'll be doing a lot of talking. But you'll also be communicating with your gestures and body language.
Never use negative body language, such as:
- Avoiding eye contact (which reduces trust)
- Crossing your arms (this is an oppositional stance and acts as a barrier to open communication)
- Leaning back with your hands on your head (makes you look like a know-it-all)
- Shaking your head, rolling your eyes, impatiently nodding (all these illustrate that you don't believe that what you're being told is 100% authentic)
Physical barriers can make a difference, too. Come out from behind your desk and don't sit with a table between you and the interviewee. The brain is programmed to react to these barriers by assuming an "us vs. them" protective posture.
6. Don't Be Scared to Identify Management Deficiencies
Deficiencies exist in every organization. Identifying and minimizing them is the surest way to achieve supremely healthy and effective operations.
Management deficiencies are a unifying characteristic of many root causes! Management always controls the means of the employee's work. Therefore, management is ultimately responsible for creating the conditions that generate accidents.
Some of the deficiencies that lead to incidents could include:
- Hiring people unsuited for the task
- Providing vehicles, equipment, and tools that are inferior or not suited for the task
- Poorly designed training or bad training delivery (for advice on delivering better training, see 7 Superb Psychological Tactics for EHS Training)
- Inconsistent or insufficiently developed reporting systems
- Lack of funding and support for required programs and initiatives
Again, don't personalize it. You're looking for systemic causes, not a person within the system that you can lay the blame on.
Get the Information You Need
Incident investigations are never fun and it can sometimes feel like they're going nowhere. But with these tips, you can make them a whole lot less painful, less confrontational, and get more of the information you need to prevent future incidents.