Reactive or Proactive: Are Incident Investigations Always Reactive?￼
Are Incident Investigations Always Reactive?
Reactive or Proactive Incident Investigations: I was reading criticism of incident investigations for performance improvement. The author said that incident investigations are always reactive. At first glance, I had to agree. After all, something had to happen to cause the incident, and the investigation was responding (reacting) to that incident.
Then I started thinking about this process a little more and thought differently about how incident investigations could be proactive. Read on for a discussion of reactive versus proactive incident investigation.
Reactive vs. Proactive Incident Investigations
First, let’s define reactive and proactive.
The Cambridge Dictionary online says:
reacting to events or situations rather than
acting first to change or prevent something:
and for proactive, it says:
taking action by causing change and
not only reacting to change when it happens:
And that got me thinking about two different kinds of incident investigations. One that is REACTIVE and one that is more PROACTIVE.
Reactive Incident Investigations
If you wait for major accidents to apply incident investigation and root cause analysis, you are definitely being reactive. I think everyone would agree with this.
And being reactive can be expensive. The Guardian reported that the cost to BP of the Deepwater Horizon accident (above) was over $65 billion.
Therefore, if the only type of incident investigation you do is after a major accident, you are being very reactive. I can see where this deserves criticism.
But reactive investigations of major accidents are NOT the only type of incident investigation.
Proactive Incident Investigations
What type of incident investigation is proactive? Investigations of Precursor Incidents.
What is a Precursor Incident? We defined a Precursor Incident as follows:
Minor incidents that could have been major accidents
if one or more Safeguards had failed.
We wrote about them here…
For example, if BP had investigated a previous “kick” that didn’t cause a major accident, they could have learned lessons to prevent the Deepwater Horizon. If they implemented fixes to improve performance and prevent future blowouts, this would be proactive change and meet the definition of proactive provided above.
That’s why I think precursor incident investigations are proactive incident investigations.
Proactive Incident Investigations – What is the Trick?
Once again, I think that everyone would agree that learning from precursor incidents is a good idea. So, what is the trick?
The trick is that management often doesn’t hear about precursor incidents or doesn’t devote the resources needed to thoroughly investigate and fix precursor incidents so that the fixes prevent potential major accidents. This is especially true for process safety incidents where there are multiple safeguards that seem to make a major accident “almost” impossible. And when things seem impossible, people get complacent.
Thus, we need to put effort into:
- Recognizing precursor incidents and making sure they get reported.
- Performing advanced root cause analysis of precursor incidents.
- Developing and implementing effective corrective actions for precursor incidents. This includes identifying and correcting Generic Causes.
- Trending incident and root cause analysis data to spot potential precursor problem areas that need additional attention.
Item 4. above makes this process even more proactive. Trending your precursor incident data can help you spot generic problems that need additional attention (better corrective actions). (Learn more about trending HERE.)
Thus, we are not only learning from a single precursor incident. We are learning from the sum total of our investigations.
Must Use Advanced Root Cause Analysis
One of the main mistakes that companies make when investigating precursor incidents is that they shortcut the investigation process. They believe that the lack of consequences that resulted from a precursor incident means that they can apply a quick and dirty root cause analysis using a technique like 5-Whys. This is a major mistake.
The first reason that it is a major mistake is that techniques like 5-Whys don’t consistently identify all the root causes in a precursor incident that need to be corrected. Look at the comparison of a 5-Why investigation with advanced root cause analysis and see how the 5-Why investigation misses several problems that need to be fixed…
The incident in the example was probably never going to cause a major accident. But the differences in the investigations do indicate the types of issues that can be left uncorrected when you apply a shortcut root cause analysis technique.
TapRooT® Root Cause Analysis for Proactive Incident Investigations
TapRooT® Root Cause Analysis is advanced root cause analysis. It meets and exceeds all the fundamental root cause analysis requirements.
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One Reply to “Reactive or Proactive: Are Incident Investigations Always Reactive?￼”
Just a comment from IT-side:
There is a common understanding in the IT-ops-world (ITIL) that anything that could immediately or in future compromise a service’s quality must be treated as incident. This incident definition includes also precursor incidents and consequently reduces the discussion whether to raise an incident or not. Whether the further processing of the incident is diligent enough is another discussion.