Ep.39 Do accident investigations actually find the root causes?
Aug 9, 2020
auto_awesome
The podcast explores the challenges of determining root causes in accident investigations, emphasizing the social aspect of the process. It discusses the importance of generating hypotheses and avoiding bias, as well as the need to address systemic issues. The limitations of current accident investigations and the flaws in the approach are also examined, proposing a new method focused on actionable recommendations and goal-setting.
Accident investigations often focus on individual mistakes rather than systemic issues, limiting the potential for meaningful organizational improvements.
Investigations are influenced by accident causation models, leading to a narrow focus on finding mistakes and reinforcing existing procedures.
Internal accident investigations should prioritize outcomes and autonomy, focusing on proposing goals and evaluating the effectiveness of actions for continuous improvement.
Deep dives
Accident investigations focus on delivering reports rather than improving safety
Accident investigations tend to prioritize delivering investigation reports rather than actually improving safety. The process often becomes a political and defensive exercise, with investigators primarily focused on finding blame and fixing individual mistakes, rather than identifying and addressing systemic issues. This emphasis on individual errors narrows the scope of the investigation and limits the potential for meaningful organizational improvements. Furthermore, investigations tend to generate recommendations that are limited to training, process changes, policy reinforcement, and paperwork modifications, rather than addressing underlying safety hazards or systemic problems. As a result, the actions derived from these investigations often fail to achieve meaningful change or prevent future incidents. Internal investigations, in particular, may avoid addressing broader organizational issues or the culpability of senior leadership, leading to incomplete and ineffective solutions. Overall, a shift in mindset, autonomy, and the purpose of investigations is needed to prioritize genuine learning and improvement, focusing on setting goals, identifying outcomes, and evaluating the effectiveness of actions.
The connection between accident causation models and investigation outcomes
The accident causation model embedded within investigation manuals heavily influences the causes identified during investigations. The principle of 'what you look for is what you find' operates in these investigations, as the model shapes the investigator's mindset and their categorization of findings. Often, investigations focus on finding mistakes or individual errors, leading to recommended actions that reinforce existing procedures, reinforce policies, or provide training. The model also affects the scope of the investigation, with some causes and factors being overlooked or minimized. This narrow focus restricts the potential for identifying and addressing systemic problems. To broaden the investigation outcomes, organizations should critically review their accident causation model, allowing for a more comprehensive understanding of factors contributing to incidents and facilitating a more proactive and holistic approach to safety improvement.
The need for outcome-focused investigations and action evaluation
Internal accident investigations should shift their focus from compliance with investigation processes to quality and outcomes. Investigators need the autonomy to take sufficient time and understand that the primary purpose is not solely to deliver a report but to identify outcomes to improve the safety of work. Recommendation and action processes should be decoupled, allowing investigators to generate findings without feeling compelled to propose easy but ineffective actions. Instead, investigators should focus on proposing goals and suggesting actions that align with those goals. These goals and actions should be evaluated for their effectiveness, and organizations should emphasize an ongoing evaluation process to gauge the impact of actions on safety improvement. By shifting the mindset and autonomy of investigators and promoting outcome-focused investigations, organizations can foster a culture of continuous improvement and genuine learning.
Considerations for accident investigations in healthcare settings
Healthcare organizations need to be mindful of the limitations and challenges specific to conducting accident investigations. Traditional root cause analysis (RCA) methodologies in healthcare often fail to explore deep system problems and tend to focus on individual mistakes and surface-level understanding. The RCA process should be supplemented with a broader analysis that examines the underlying system problems and vulnerabilities. The quality and safety committees within healthcare organizations should be open to examining the effectiveness of their own practices and policies, rather than solely attributing incidents to frontline errors. By adopting a more comprehensive and systemic approach, healthcare organizations can uncover critical insights and implement meaningful changes to enhance patient safety.
The importance of external investigations and diverse perspectives
External investigations, conducted by independent parties, can offer a fresh and unbiased perspective on incident causation and potential improvements. Internal investigations tend to be influenced by organizational pressures and may prioritize individual blame over systemic issues. External investigators may be more open to attributing root causes to external factors, such as regulatory gaps or macroeconomic influences. Their insights can provide valuable recommendations that challenge organizational norms and highlight systemic issues that often go unaddressed. Embracing external investigations and diverse perspectives can lead to more accurate and effective identification of root causes, enabling organizations to implement appropriate corrective actions and improve overall safety performance.
To frame our chat, we reference the papers, Our Current Approach to Root Cause Analysis and What-You-Look-for-is-What-You-Find.
Tune in to hear our thoughts on this matter.
Topics:
Determining root causes of accidents.
Why investigations are social processes.
An explainer on editorials.
What “process change” really means.
Applying the Swiss Cheese Model.
Confirmation bias in research.
Only finding what you can fix.
The difference between internal and external investigations.
Practical takeaways from the studies.
Quotes:
“What they suggested was that we should always have a very strong evaluation process around any corrective action to test and check whether it actually addresses the things that we’re trying to address.”
“To really understand how the investigation has happened, you’ve got to talk to the investigators as they’re doing the investigation…”
“I can’t imagine a safety person taking to the board a recommendation that they weren’t sure themselves, they could fix.”
