What do we do when investigating events? 

There is a quote from Todd Conklin which really sticks with me & that is ‘Telling me an event or incident was caused by a worker who failed to follow procedure is like telling me that something fell due to gravity’. It’s always true, it just doesn’t tell me anything. I really love that. I see it so often in organisations where they have an unwanted “event” and they do an investigation & it comes back with a workers fail to follow procedure. And that is where they stop! They haven’t learnt anything. The other slide I like from the course is a quote from Andrea Baker. It was ‘How I viewed the driver affected the questions I asked of the person, the questions I asked affected my solutions and then those solutions still left us open to the possibility to people being hurt.’ To me that’s a really good way of saying if you already go into an investigation with the belief that its someone fault or someone’s to blame, or the driver or the operator did the wrong thing, that will colour the questions you ask. Straight away your bias so therefore you only ask those questions about the driver, not about the systems. If you only ask the questions about the driver, you are going to identify problems with the driver, the solutions will only be about the driver and you will have missed 99% of what normally happens in this space where we don’t have an event. That’s traditionally what’s been happening in organisations trying to understand & learn from events. The HOP approach really takes that away.

Mark Alston | Proudly brought to you by Southpac International.

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