When Deciding Who to Interview, Work Your Way Around the Target!
One of the first dilemmas facing any investigator is deciding what data you need and what you have to have. There are many theories on this topic, but one rule of thumb I like to use is to, work your way around the target.
In the 7-Step Process Flow, Step 1 + 2 comprise the “What” portion of the investigation where we begin the process of trying to understand what our Incident is, and what let up to and followed it. During this time we work with our SnapCharT® to aid us in organizing and understanding the data we collect.
Data comes in many forms including our 3P’s + R; People, Paper, Plant, and Recordings. All of these forms of data are important to helping us understand the initiation of and the genesis of an incident. These different data types fit together to weave a picture of the incident and provides us with the basis for our analyses moving forward. For most, the first place we start is with anyone involved with the incident to get their first hand accounts of “What” happened and “Why”. By taking this very simplistic approach we can begin the process of vetting out truth and fiction, fact and opinion. But this is only one subset of people we must interview to fully understand an incident.
Working your way around the target means thinking about anyone who might have influence on an incident and making sure we interview and gather all perspectives.
Think of the incident/accident as a target, with concentric rings moving outward from the center. Each ring further from the center has less direct knowledge but can provide very valuable perspective. We need to understand everything surrounding the incident to fully evaluate for and understand the root causes. So there are various levels of knowledge and influence that we should consider.
Inner Circle – Those Involved: These people will give you your best starting point and the most information directly related to the incident/accident. Most direct knowledge will be found here.
Second Circle – Those Around or Near the Incident: This group can provide interesting information that might help you piece together what you know. They may or may not have any direct knowledge but can provide things such as what was heard, felt, smelled, tasted and sensed. Much of this can be used by the investigator understand information provided by those involved and can many times provide very simple yet important pieces to the investigative puzzle.
Third Circle – Subject Matter Experts (SMEs): When trying to understand a process or failure, SMEs provide an invaluable resource. Their knowledge can allow the investigator to understand successful performance and what should have happened. This can be used to understand both Equipment and Human Performance related failures. By understanding proper performance the investigator can more easily identify where potential failures exist. By understanding how processes or systems fail we can more easily identify Causal Factors.
Fourth “Dotted” Circle – Those with Influence on the Incident: Working with many investigative teams I have found that many facilitators only consider those members of management with direct involvement in the incident. That could include a direct line supervisor or a local area manager. By approaching this group in this manner the investigator can lose sight of a very important piece of work culture. That missing piece is the “Expectation”. What is communicated and expected can many times be in opposition and create confusion or problems in the work place. I believe to fully understand an incident and its causes the investigator should reach out to differing layers of management and talk about what is the “Expectation” for performance of whatever jobs are involved. This “Expectation” can not be used as fact but can aid in the understanding of decisions made and actions taken by those involved in the incident.
If the investigator works their way around the target, and ensure that these different perspectives are understood, they will have a better more thorough understanding of the incident and can perform a more thorough and complete root cause analysis.
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