Incident Investigation: Five Ways to Tell If Investigations Need Improvement
Incident Investigation: Does Your Process Need Improvement?
Incident Investigation … Do your incident investigations need improvement?
Of course, you should answer this question with a “Yes!”
Why? Because all processes need to be continually improved. In my experience, the companies with the BEST incident investigation processes are usually the same companies that are trying the hardest to improve their investigation processes.
But here is the most surprising observation from my experience. The companies with the WORST incident investigation processes usually don’t even know that their system is substandard.
Why? Because they:
- don’t benchmark,
- don’t have performance measures,
- don’t grade their investigations,
- don’t have management that insists on better investigations,
- don’t listen to regulatory advice, and
- don’t listen to their investigators who really don’t want to perform incident investigations.
Probably the biggest problem I see is that companies have major accidents and never ask the question:
Why didn’t our previous investigations stop this from happening?
The question seems so obvious to me.
Here is more about the fundamentals of incident investigation if you need a refresher before you read on…
Now, please read on and see the five indicators that you need to improve your incident investigations.
5 Signs You Need To Improve Your Incident Investigations
What are the five signs you need to improve your incident investigations?
- A Major Accident
- Repeat Incidents
- Dissatisfied Management
- Dissatisfied Regulators
- Dissatisfied Incident Investigators
We already briefly described the first sign that you need to improve – you had a major accident. Let’s look at the other four.
First, most major accidents are preceded by precursor incidents.
These precursor incidents are warnings. You should be learning from these precursor incidents to stop major accidents. If you don’t stop the precursor incidents, the clock is ticking until a major accident happens.
Therefore, repeat incidents are a warning and if you have them, you need to improve your incident investigations!
Of course, you want your boss (and all of the senior management) to be happy with the results of an incident investigation.
If they aren’t happy, you should be asking, “Why?”
It could be that they have unreasonable expectations. They want all investigations to be finished with minimal effort and have corrective actions that require little to no work.
If unreasonable expectations your problem, no amount of incident investigation improvement will help you meet management’s expectations. You need help getting your management to understand what a reasonable incident investigation and corrective actions can accomplish. Contact us about an executive briefing to set their expectations.
But what if management is being reasonable. They are willing to provide the resources for an investigation and the follow up corrective actions, BUT they don’t:
- like the answers your investigations are providing.
- think your corrective actions will be effective.
- understand how the accident happened.
- understand the presentations or reports that you produce.
They may even realize that they have seen this incident before and that the corrective actions didn’t stop a repeat incident (repeat incidents).
In those cases, management is asking you to improve your incident investigations. Once again, you need to respond by making improved incident investigations happen.
If your regulatory oversight is complaining about your incident investigations, you are in trouble.
It could be:
- the FDA sending you a Warning Letter about a problem (about 50% of these letters mention substandard investigations).
- The NRC scheduling a Special Inspection after an incident at your nuclear plant.
- The EPA taking enforcement action after an environmental incident or, even worse, initiating a criminal investigation.
- OSHA taking enforcement action after a serious injury or fatality or, worse yet, adding your site to the Severe Violator Enforcement Program.
No matter who your regulator is, if your regulator is taking enforcement action, you need to improve your incident investigations.
Dissatisfied Incident Investigators
Dissatisfied incident investigators are probably the trickiest of the dissatisfied “clients.”
Why? Because you could be tempted to say:
“Tough luck. Do your job.”
But feedback from investigators that they don’t want to perform investigations is important. It could indicate:
- a lack of management support for the incident investigations (including the resources to perform the investigations),
- confrontational incident reviews by management,
- a poor investigation system, or
- a lack of training for investigators.
The items above are just the start of the list. Dissatisfied investigators mean that you have work to do to improve your incident investigation process.
Improve Your Incident Investigations
If you have decided that your incident investigation process needs improvement, we would be glad to help. Contact us at 865-539-2139 or CLICK HERE, and we will be glad to discuss your issues and potential solutions.
The thing you DON’T want to do is wait. Waiting seldom makes a problem go away. Instead, it allows the problem to grow. It could allow a major accident or quality issue occur that you should have been able to prevent.