A lot of times during an incident investigation, our conversations will begin with managers or people who are familiar with what occurred but may not have been present. This information is a great start into understanding what happened but often it’s just the beginning. As we keep digging into the roots of the issue(s), I generally recommend we talk to frontline employees who were closer to the incident for clarity about decisions that were made. I want to understand their assumptions, their mindset, their experience, the tools and resources they have available to them regarding their decisions that lead up to the event.
As the investigation evolves, it typically becomes obvious that specific details were left out of the initial conversations that greatly enhance the findings of the investigation – leading to more effective solutions.
If we ask enough “why” questions during the investigations, we will back into work processes or procedures that didn’t go well. Often times it’s the way someone has always executed or carried out a specific task. However, this time, something was slightly different, and it resulted in an incident. A common management response I hear is “there’s a procedure for that” or “they should be doing it like this per company protocol.” It often turns out, when looking at a specific procedure or protocol, the step or decision that “broke down” and resulted in the incident isn’t even mentioned in the document.
Management of Change
Management of change is a common example. Most organizations have a procedure listing out how to perform this process. During the investigation, we may discover that the employee who was involved recently started and didn’t remember or wasn’t told that there is a procedure for the task. In the initial steps of the investigation, we are often told “they were trained.” But is it realistic to assume that the information from the training was retained when they came to the site and were inundated with site and company protocols WHILE learning about specific operations pertinent to their role?
Different Interpretations
Maybe the employee knew about the procedure but assumed it did not apply because the “change” didn’t meet the documented definition of “change.” My interpretation of a word, of a requirement or instruction may be different than yours. Have you ever asked a child to clean their room? Without following up on expectations, their interpretation of clean may be a little different than your own.
Everyone Knows This
Or maybe experience and/or tribal knowledge is relied upon during certain steps of the work process that were just unclear to the new employee. “Everyone knows this needs to happen” is something we commonly hear, but if everyone knew, we wouldn’t be investigating an incident. Someone who has more experience with the process may not recognize the need for detail or clarify in the documentation.
The Frontline is Important
We don’t understand these details until we talk to frontline employees. Without the detailed information that frontline employees can provide, investigations often result in generic solutions like “retrain employees.” Details about what didn’t go well are needed to develop effective, detailed solutions so it’s critical that we understand the specifics.
Most of the time, people do not show up to work with the intention of making mistakes. So, after an incident occurs, let’s involve the employee(s) to understand their actions and decisions; not to blame but to understand. They have a lot of valuable knowledge that can greatly enhance incident investigations and enhance the reliability of work process(es) moving forward.
5-Why for Frontline Professionals
Frontline employees should be problem-solving lookouts for your organization. The closer that problem analysis is moved to the day-to-day work, the better an organization’s ability to respond and reduce the likelihood of catastrophic events. This is one of the advantages of 5-Why Cause Mapping® Root Cause Analysis for the frontline.
