January 21, 2008 | Mark Paradies

Monday Accident & Lessons Learned: What To Do When the “Facts” Don’t Agree Part II

Back in December, I wrote about an accident investigation that was never completed because the “facts” didn’t agree. I asked “How would readers complete the investigation” and asked for comments. The comments can be seen at:

http://www.taproot.com/content/2007/12/10/monday-accident-lessons-learned-what-to-do-when-the-facts-dont-agree/

Having conflicting information is a common problem when investigating an accident.

The best way to detect conflicting information (facts that don’t match) is to put the information collected on a SnapCharT®.

Using a SnapCharT® to display the information sometimes will make the non-factual information obvious (it doesn’t agree with the other stories or the physical evidence). Other times, either story is possible, and you can display how each set of facts is plausible.

What do you do when you have two sets of plausible stories? I try to analyze each possibility, develop causal factors for both stories, analyze each stories root causes, and then look at the potential corrective actions. If I can develop corrective actions that correct the root causes for BOTH stories, I don’t have to know which one is right. If I can’t develop effective corrective actions that will prevent the recurrence of both stories, then I need two sets of corrective actions, one for each story.

In my experience, the main reason (although not the only reason) for conflicting stories is that people are trying to avoid blame and are are either:

1. Telling the investigator a story that won’t get them in trouble.

OR

2. Telling the investigator what they think the investigator wants to hear (to keep the interviewee out of trouble).

The best way to avoid people “telling stories” is to develop a “just culture” or “no blame” environment where accident/incident investigations are seen as performance improvement opportunities rather than witch-hunts. Making this change requires senior management support.

WHAT DO YOU THINK?

Are my suggestions a practical way to deal with conflicting “facts.”

Leave a comment and let me know what you think.

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