Customise the Process or Not?
This article explores the customisation of a standard process by an organisation and the impact it has on the fundamental principles of the process, and whether the customisation enhances or diminishes the effectiveness of the process.
As an organisation strives for operational excellence by looking to improve upon its systems and processes, the organisation typically associates itself with leading industry initiatives and searches for an existing and proven process, as opposed to undertaking the time-consuming development of an in-house method. Most often this is achieved through research and consultation by looking at other users’ experiences, challenges, benefits, acceptance, appraisals, and recommendations on the process to enable an informed decision regarding applying the process methodology within their business. Put simply, looking to utilise existing industry best practices to demonstrate effective and quality outcomes within their operations.
The Merriam-Webster Dictionary defines ‘best practice’ being “a procedure that has been shown by research and experience to produce optimal results and that is established or proposed as a standard suitable for widespread adoption.”
Too often, though, there are instances where an organisation may need to modify that process to customise to meet specific internal requirements. While this has good merit, the question we must ask ourselves is; “have we over-complicated the process by adding redundant elements and unintentionally compromising the application and fundamental principles of the original process?”
In this article, the process being put to the above question is the “incident investigation methodology” used for a system-level investigation of a workplace incident.
The System-level Incident Investigation Process
A system-level incident investigation examines the contributing factors to an incident, with the focus being on identifying latent systemic health, safety and environmental deficiencies within the organisation’s systems and processes. Additionally, the investigation includes both cultural and behavioural aspects which may impact the operational discipline to the application of process, which may or may not, have contributed to the incident.
The Incident Cause Analysis Method (ICAM) is a system-level incident investigation methodology and is a leading causation investigation model widely recognised across industries.
The methodology of ICAM consists of four core stages which underpin the fundamentals of an investigation of asking key questions of ‘Who, What, When, Where, Why and How.’ The four stages of investigation include:
1. Data Gathering
2. Data Organisation
3. Data Analysis
4. Recommended Corrective Actions
Each stage is designed to play a specific part in the investigation process, with each stage dependent on the other for an effective and quality outcome providing the desired result. This design allows the process to be intuitive and demands a check-based approach from one stage to the next to deliver repeatable results between various investigators.
This methodology is designed to overlay the many organisation investigation procedures being used across a wide variety of industries. Each industry organisation customises the ICAM to align with its needs. This is important as each industry does have its unique characteristics; however, have we sometimes been over-zealous in creating in-house modifications and (so-called) ‘improvements’ that can be counter-productive with redundant elements, thus unintentionally creating inconsistency in quality between investigations and investigators?
Let us examine these customised modifications and determine if they are adding value by being smarter or if these additions or exclusions erode the fundamental principles compromising an effective investigation. Firstly, we should unpack the four core stages of the investigation methodology into their basic elements and consider the impact on the investigation process by the common additions and exclusions currently adopted by some organisations.
The ICAM uses the simple and effective ‘PEEPO’ technique covering the five data sources for gathering information which consists of:
The application of the ‘PEEPO’ is composed of two separate parts to gather the data. These parts being ‘PEEPO Mark1’ and ‘PEEPO Mark2.’
PEEPO Mark1 - Plan for what you are going to collect. This is based on limited information about the incident, where the investigation team comes together and brainstorms the data sources for the information required.
This is the pre-gathering planning. It is essential that the investigator initially spends a short amount of time brainstorming what data to gather and the various sources for gathering that data. Basically, there are four questions to ask during this planning step:
· What was the task?
· What is the Safe System of Work (industry benchmarks for safe execution) for the task?
· How was the task actually performed?
· What are possible organisational and environmental conditions that could adversely affect how the task was performed?
This step develops the plan to gather data which is critical for efficiency and effectiveness, laying the foundation for the overall investigation.
PEEPO Mark2 - This is the factual data that distinguishes between non-contributing factors and contributing factors to the incident.
The objective of the data gathering is to determine the contributing factors for analysis of the causal factors to the incident.
The ‘PEEPO’ technique also considers the following work sequence to assist in determining the contributing factors. The work sequences are:
· Work as Done.
· Work as Intended.
· Work as Normal.
This step simply becomes a gap analysis where any of the gaps that adversely affect the safe system of work are identified.
The challenge for some organisations or investigators is not to be tempted to exclude or skip the planning stage (PEEPO Mark1) because of various opposing influences such as time constraints, insufficient resourcing, pre-conceived ideas that this investigation is straightforward, not fully understanding the elements of ‘PEEPO’ and pressure from external parties for quick answers. The planning stage of the PEEPO Mark1 is paramount to delivering an efficient and effective PEEPO Mark2.
Like any successful project, the work must be planned. Good planning is directly related to efficient applications producing quality results.
The organisation of the data gathered is typically configured using a timeline that initiates the ‘5 Whys’ questioning technique to consolidate and validate the data and ensure that the relevant contributing factors have been identified.
Timeline - This is simply a sequence of events, including pre-incident events, the incident, and post-incident events. It is a graphical representation using time and events put into a logical sequence.
5 Whys - Often considered an additional but optional technique within the ICAM used to determine the root causes (deficient organisational factors) of an event in the timeline and steers the investigation to look beyond any human error. This assists in transitioning the contributing factors into the next step, the Data Analysis.
This is the investigation stage in which the majority of modifications or customisations are made to the investigation process, which can induce varying interpretations by the users and, subsequently, vary the quality of the investigation.
To determine the value of any change, we need to examine the various modifications known and demonstrated across industry.
The ‘5 Whys’ is one of the oldest investigation methodologies in history to determine root causes and engages the basic technique of asking ‘why’ to get to the root cause of an incident. The common trap people can fall into is thinking it is a quick and easy way to investigate, and therefore believe there is little or no point in going to the next step of the ICAM Analysis if this can deliver what is needed. There is also a perception across industry that people should not need to undergo much training to simply ask ‘why’ and ‘just follow the report template.’
To the untrained person conducting the investigation, the ‘5 Whys’ can be quite complicated and frustrating because the key to an effective ‘5 Whys’ is identifying the appropriate ‘problem question’ to ask about a significant event on the timeline. Unfortunately, the key question is not always identified and asked therefore steering the ‘5 Whys’ in a direction that can lead to being outside the scope of the investigation. Additionally, not enough or too many ‘why’ questions can be asked that miss the root cause entirely. Systemic latent conditions can go unnoticed and remain unaddressed in the system due to the ‘5 Whys’ being subjective due to bias with the investigator.
To try and address the above-mentioned issue, another modification in the timeline has been adopted by some organisations. The timeline gets expanded into three different timelines, which generally consist of:
· Work as Done.
· Work as Intended.
· Work as Normal.
When we look back to the initial stages of the investigation, all the above three timelines are covered in the first stage of data gathering, the “PEEPO.” To comprehensively construct each of these timelines can overcomplicate this element of the data organisation and extend the time of the investigation while providing little or no additional value.
Firstly, ‘Work as Done’ is a simple timeline representing what occurred and sets up the process to apply the ‘5 Whys’ questioning technique.
‘Work as Intended’ is simply what should have occurred by the documented procedures of the organisation. Looking at this holistically across the investigation, this work has been completed in the ‘PEEPO’ as part of the gap analysis against industry benchmarks and actual performance. The real value of ‘Work as Intended’ is that it assists in asking the ‘problem question’ to the event in the ‘5 Whys’ process. Constructing a formal timeline can be quite detailed and time-consuming when it simply prompts a question to ask.
‘Work as Normal’ has focused on behavioural and cultural aspects and again is in the ‘PEEPO’ stage of the investigation. This timeline could be the same as either ‘Work as Done’ or ‘Work as Intended.’ This is covered when the investigator determines the type of error, which is also covered in the ‘PEEPO’ stage and validated in the Analysis stage.
The challenge is not to try to reduce the investigation timeframe by doing the analysis in the data organisation stage by being fixated on the ‘5 Whys’ as the Analysis Tool. Adding more variations of the timeline to try to achieve a quality analysis using only the ‘5 Whys’ appears to defeat the purpose of using the more detailed and thorough ICAM Analysis. A question to ask is, “Would it not be more effective and efficient to go to the next step of ICAM Analysis?”
The ICAM Data Analysis is the heart of ICAM providing effective analysis of the contributing factors obtained from the Data Gathering and Data Organisation stages. It provides a comprehensive analysis by categorising contributing factors into specific groups being:
· Absent / Failed Defences
· Individual / Team Actions
· Task / Environmental Conditions
· Organisational Factors
The ‘5 Whys’ consolidates the data in the Data Organisation stage, enabling a smooth transition of the contributing factors into the ICAM Analysis.
The analysis provides a clear pathway of the causal factors to the incident and specifically defines any errors made by individuals to support a ‘fair and just’ culture.
Some organisations treat the ICAM Analysis as a complex component of the investigation methodology and therefore consider it best suited to just high-level incidents. However, looking at the investigation as a whole, the completion of the ICAM Analysis is only a small portion of the overall timeframe for the entire investigation. The time-consuming stage is the data gathering which is the standard component of any investigation model. Removal of this ICAM Analysis step in preference to only relying upon the ‘5 Whys’ Analysis should be carefully considered as it can leave the organisation with gaps in its investigation. The ‘5 Whys’ technique requires a good level of knowledge and skill, as does the ICAM Analysis process.
Recommended Corrective Actions
The recommended corrective actions are developed to prevent recurrence by addressing all the contributing factors. Organisations are consistent in how this stage is completed; however, the outcomes can vary due to the quality of the data gathering and analysis in the earlier steps.
It is important to understand that all incidents should be investigated by applying the same four core elements because the process does not change. The only change is the amount of data and detail to work through. Organisations determine the level of investigation based on risk, addressing both actual and potential consequences. The higher the risk level for the incident, the investigation is more likely to undergo an ICAM Analysis, and for lower-level incidents, the ‘5 Whys’ Analysis is preferred. In practice, conducting a ‘5 Whys’ Analysis requires the same amount of time and resources as an ICAM Analysis, no matter what the category of incident and risk level.
The amount and level of detail determine the complexity of the investigation. The benefit of using the ICAM Analysis for complex investigations is that it provides a more structured and detailed outcome with contributing factors being clearly defined. Additionally, there is a place to use the ‘5 Whys’ to support the ICAM Analysis as it assists in gaining a better understanding of the data and forces the probing questions of ‘why’ to identify the root causes. This aids a smooth transition of the contributing factors into the ICAM Analysis. However, when the ‘5 Whys’ has been the preferred methodology, organisations then feel the need to assist the process by constructing additional timelines, as discussed earlier. This then adds unnecessary layer upon layer to an already solid and proven process.
The investigation is one of many processes with specific procedures in an organisation and should be treated the same as any other process in the field by being risk assessed and resourced adequately with appropriately trained people. To ensure good performance, the investigation team is having an intuitive and effective proven process to follow with adequate resourcing of the investigation with the right people, tools, and time. This minimises any risk of human error by the investigation team where system deficiencies have been missed and remained unaddressed. This warrants the investigation as inadequate and leaving the organisation at risk of an incident recurrence.
The timeframe of any investigation is directly proportional to the level of detail. Do we really need to add extra timelines and only apply the ‘5 Whys’ as the analysis tool, or should we adhere to an industry-proven process and resource the investigation to the standard required to deliver a quality outcome?
This article is written to question the need for modification or customisation to enhance the investigation process within your organisation. It is to challenge the organisation to analyse what is needed to be achieved from these changes - will it add value, will it assist the investigation for efficiency and effectiveness, and does it help the investigator? If the answers to these questions are positive, then the changes become improvements and benefit the organisation.
Interested in knowing more?
Further information on Safety Wise Solutions, ICAM Training and other services is available from our website: http://www.safetywise.com
Additional ICAM Related Services
Safety Wise Solutions 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
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