Part 3: Improving your safety investigations
April 12, 2010
This is the third part in a three-part series.
The road to improving your investigations already exists and is well marked. There is a logical order in the six steps necessary on this journey.
In Stage 1, you must review the policy and procedures you have in place to assure they provide clear and unambiguous direction to the organization. The areas that will typically require some work are:
What incidents will be investigated to what level? This determination should be made with the potential severity in mind (not just the actual outcome in this instance) and the potential for recurrence.
How will incidents be screened and evaluated? Your procedures should call for an immediate assessment on the available data, with a quick start to the investigation.
Who is in your pool of investigators? As an organization, you need to decide whom you will call on to investigate, and then actually use these people when the need arises.
What training and experience levels do our investigators need? The skills for information assessment and interviewing require both classroom and demonstrated exercises to be effective and those trained need to have opportunities to use these skills to hone and improve them over time.
In Stage 2, the focus is on starting a specific investigation quickly and in the right manner. The key issues include:
Quickly establish the investigation team. People need to be pre-identified and trained, and given the knowledge they will be asked to serve in this capacity.
Relieve the investigators of their normal assignment.
Take steps to properly preserve the scene of the incident.
Establish the legal framework for the investigation. Many organizations lose valuable time having a debate around each occurrence whether the investigation will be done under legal privilege.
Do only one investigation. Avoid the trap of having each interested part of the organization conduct their own inquiry into the event.
In Stage 3, the appointed investigation team conducts the investigation of the specific incident. The key issues:
The investigation team retains control of the incident scene until they release it. This authority needs to be given to the team to allow them the necessary time and space to do quality work.
An agreed Terms of Reference document governs the activities of the investigation team and the rest of the organization. Since the investigation team is an ad hoc group by nature, its place, its interactions and its roles and responsibilities need to be clearly defined.
The investigation team needs to follow their training. This is especially an issue in the first few investigations people will do after training.
Write it up
In Stage 4, the team compiles its findings into a written report. The issues at this stage include:
There needs to be a formal written record of the investigation. The level of detail can vary by the severity of the incident and the use of one or more templates can help improve the quality of the reporting.
The report contains the recommendations of the investigation team. The team is in the best position to make recommendations with respect to what needs to be done.
In Stage 5, the organization must act to implement the corrective actions. Typical issues that arise at this stage:
The report is addressed to the right person in the organization.
The person receiving the report has the final authority to accept or reject recommendations.
The person receiving the report has the responsibility to act on the agreed recommendations.
The actions are tracked to completion. There should be a routine audit function to verify agreed actions are completed in a timely manner and should, over time, seek to measure effectiveness of the recommendations in preventing future events.
Information about the incident is shared as necessary. Each report should be evaluated in this regard and appropriate information communicated to others.
In Stage 6, the investigation team has now completed its work and members have returned to their normal assignments. One issue remains.
The report recipient should provide feedback to the investigation team. In the absence of feedback, the team and its individual members have every right to think they did a perfect job and to perform in the same way next time. Feedback is critical to continuous improvement.
What do you think?
I’d like to know how you react to my thoughts on investigations. Email me at firstname.lastname@example.org.