Engaging Stakeholders in Incident Investigations
Here’s a bit of my background in this most recent investigation…
I’m a back up member of an organization’s investigation
team and last month I had the opportunity to conduct a serious
near miss incident investigation, and then a few weeks later presented
my findings to a group of stakeholders in the form of a Power
Point presentation. The stakeholder group included the workers
directly involved in the incident, their supervisors both on site
and off site, contractors and senior management for the area.
This organization like all my clients shall remain nameless.
They are unique in their approach to investigations, in that they
have full time root cause investigators, and they treat investigations
as a true learning and improvement opportunity through the involvement
of stakeholders in addressing incident causes.
With the exception of using dedicated investigators their initial
investigation process is not unlike others. After the scene has
been visited, physical evidence gathered, and witnesses interviewed,
a report is produced containing only the facts of the matter which
include both the physical and human causes of the incident. While
the investigator might include some thoughts about corrective
actions, their purpose is only to stimulate discussion. The opinions
of the investigator are not part of the report. The belief being
that when the facts are presented to the stakeholders they will
speak for themselves and no other input or commentary is necessary.
(This was different for me as I’m usually expected to offer
an expert opinion as to cause and levels of responsibility.)
Once the stakeholders have seen the photographs, sketches and
facts obtained from both witness and investigator observations,
and are satisfied they are accurate; the meeting is turned over
to the stakeholders. The presenter’s role now becomes one
of simply guiding the discussion as stakeholders review the events
and come to conclusions as to causes and corrective actions.
As all the stakeholders are present, finger pointing seldom occurs,
but rather an honest examination and discussion of both individual
and organization causal factors occurs. The meeting concludes
with stakeholders identifying corrective actions and jointly agreeing
on completion time lines and the stakeholder responsible for overseeing
the completion of the corrective actions.
This exercise took a half day with about one third of the time
allocated to the presentation and the balance to the stakeholder
discussion. I found it interesting that one of the potential corrective
actions I had identified never saw the light of day after the
stakeholder discussion. This serves to point out the power of
this process in that what I initially felt might be a good fix
didn’t fit with where the stakeholders were heading.
No doubt many of you solicit input from similar stakeholder groups
during your investigations and incorporate it into your findings
and recommendations. The main difference here is that all the
stakeholders are present at the same time, and the facts are laid
before them. As they are facts, there’s little need to discuss
the “what happened” as compared to the “why”
and the “how” we are going to fix it.
This brief explanation does not do justice to the process. It’s
something that you wouldn’t use for every incident, but
rather for high potential incidents or near miss situations. If
you are thinking there might be an opportunity to try this in
your organization and want some more information give me a call,
and I walk you through the process in more detail.
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