THE IMPORTANCE OF FOCUSING ON THE ORGANISATIONAL FACTORS DURING AN INVESTIGATION
For those of you who read my previous article you will be familiar with Zoey, our 5 year old daughter. It seems that she is becoming my inspiration and the common theme to all my discussions around ‘everything investigation’. So, here she is again demonstrating with a scenario which most of us can relate to, another important principle of ICAM and reinforcing that you can honestly ICAM anything… Dinner time is dreaded in our household. Zoey is easily distracted and we spend hours at the table trying to encourage her to finish her meals. Ultimately, one of us leaves the table out of sheer frustration leaving the other parent to deal with the fallout. On one such occasion we both left, leaving Zoey with a half finished plate of food in front of her, with the instruction that she must finish her food if she wants to watch any TV. It must have been only 5 minutes later when she went to her dad to tell him she was done. Skeptical, he asked her how she had managed to finish all that food so quickly and she responded proudly with a mouth full of food, “dad, I just stuffed it in there”. Knowing what we know about our daughter, we knew there was no way she was telling the truth. Jordan looked at the dog who was still asleep on his bed and then started moving towards the dustbin. That’s when Zoey panicked. She ran to the bin, held the lid down and begged him not to open it. No guesses now where the dinner went. Needless to say she was reprimanded and had to eat some of her dinner from the bin (don’t worry the bin did not have garbage in it), and then had to help out with the dishes. My husband seemed very satisfied. When I look back I have to ask myself what she learnt from this? If she did learn a lesson, was it the right one? Did we really understand why she did what she did? Did we set her up for failure? Did we respond appropriately - does punishment change the unwanted behavior and mean that it won’t happen again? Probably not. I bet that we just taught her that the next time she should hide it better, or better yet, give it to the dog! This anecdote is easily applied to our industry investigations too. If an organisation really wants to effect positive change they need to identify and understand what really went wrong; to go beyond ‘what’ happened, to explain ‘why’ it happened. This requires a shift in focus from the individual (person model) to the organisation (systemic approach) where errors are seen as consequences and not causes of an event. Think of an incident in your organization where human error was found to be the cause. Based on this finding the recommendations were probably along the lines of discipline or possibly even termination. Now, consider the next person in your organization who is presented with the same or similar scenario under similar conditions. Can you be sure that they would not make the same or similar mistake? The aim of the investigation should be reduction of risk and prevention of recurrence. Implementing controls that deal with the individual errors alone (superficial findings), like counselling and discipline, do not reduce the risk around the activity or reduce the likelihood of a repeat event, and in some cases may even drive down the reporting. Just think back to Zoey and what happens the next time she is left alone to eat her dinner. We haven’t changed the conditions, but we are expecting a change in behavior. This is unlikely. A systemic investigation identifies human error, whether intentional or unintentional, but does not focus solely on the individuals and the errors they made as this only provides a superficial explanation of the event. Rather it accepts that human error is inevitable and attempts to put the human error in context to better understand why the errors occurred. The investigation digs deeper and identifies the organizational factors which are the underlying factors that produce the conditions that affect performance in the workplace. These are the latent conditions that contributed to the actions or the context in which they occurred. Understanding why Zoey made the decision she did should help us to implement better controls to prevent similar behavior in the future. Why did she throw the food in the bin? Because she knows she is supposed to eat it but she’s not hungry. Why is she not hungry? Because she only eats her lunch at 3:15pm, after school. Why does she eat her lunch so late in the day? Because at recess the monitors are not enforcing the rule that the kids have to eat their lunch before they can go play. Why aren’t they enforcing it? The monitors are kids at the school, not teachers/ experienced child minders. Why aren’t the teachers doing it? Possible time, budget and personnel constraints. These are some of the potential underlying causes. From an industry perspective we have identified the organisational factor(s). It is far more effective for an investigation to focus on these system failures (organisational factors) as these are the contributing factors that the organisation is able to control and/ or change. These organisational factors include management decisions, processes and practices such as poor design, inadequate risk management, poor culture, ineffective procedures, lack of training, poor management of change, incompatible goals, organisational learning and many more. Professor James Reasons states that “we cannot change the human condition but we can change the conditions under which humans work” and this is the entire premise of ICAM – failure should be seen as a system issue, not a person issue, which then provides an opportunity for the organization to really learn from the event. Addressing the organisational factors will likely remove some, if not all, of the adverse conditions that influence human performance. By identifying and addressing the organisational factors and implementing effective controls the organisation gets better at preventing future errors, or at a minimum, traps and mitigates them to reduce harm. Through this process the organistation is more effective at reducing risk and preventing recurrence. Let’s go back to Zoey. If we use parents as volunteers (removes budget issue) or teachers (where resources permit) who have experience with kids and understand the importance of nutrition then we increase the likelihood that Zoey eats her lunch at recess, thus removing the conditions that she is hungry at 3pm, which means she is more likely to be hungry at dinner time and eat her dinner than rather throw it in the dustbin.
Interested in Knowing More?
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Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Mary-Jane Vince (Investigator/Trainer)
Mary-Jane has 12 years’ experience in the mining industry in Africa, North and South America developing best practice EHS management systems built across entire life of mine processes, from exploration, permitting, greenfield/brownfield construction, start up and commissioning, operations and closure.
The combination of technical skills and knowledge supported by practical industry experience with people of different cultural backgrounds has given Mary-Jane a high level of communication, understanding and adaptability to provide effective health and safety advisory and training services.
Her work has brought her into many unique and sensitive operating environments and as a result she is comfortable in multi-cultural stakeholder engagement, working with organisations, local communities and government to find mutually beneficial solutions to challenges in mine operations, expansion, rehabilitation and closure.
Mary-Jane joined the Safety Wise team in 2012 working in North America and Botswana, before recently relocating to Canada providing ICAM training, investigation and consulting services for clients in multiple industries.