How to Move an Investigation Past Preconceived Ideas

Renata Martinez

Have you ever held a kickoff meeting for an incident investigation and someone immediately claims to “know what the problem is?” People can have strong views on what the problem is and how to fix it before the investigation even begins.

I want to address this common challenge facilitators face and some ways to effectively defuse preconceived ideas while keeping the investigation team focused and the investigation moving forward.

Assembling the Team

Before scheduling the investigation kickoff meeting, start working on the problem outline to understand (on a high level, from your point of view) what happened. By taking a look at which goals are impacted, it often becomes obvious who the key players are. Comprise your team of people who were close to the work (frontline personnel) and people in managerial roles. By getting the appropriate people in the room during the investigation, it allows an immediate difference of perspectives and the ability to effectively discuss differing views. You can then edit the Cause Map™ diagram as causes are revealed—capturing what everyone perceives as the “issue” and proving or disproving causes using evidence.

As a facilitator, you do not need to be a subject matter expert on the incident, the equipment and/or related process(es). In fact, it’s helpful to have an outside perspective. Often, when we are too close to a problem, we have blinders on and can miss obvious causes. The facilitator can help explain a complicated issue using subject matter experts to fill in the “how” and “why” questions.

Defining the Problem

It’s not necessarily a bad thing if you have a boisterous voice in the room who happens to know everything, because that strong perspective can initiate discussions and ideas. However, we don’t want a single perspective to drive the whole investigation. If you’re working on the problem outline and someone tells you what the problem is, write it down in the “problem” box of the problem outline. Keep in mind, you aren’t limited to one problem—you can list multiple problems on the outline. Make as much room as necessary in that cell (if you are using the Cause Mapping Excel Template), and write down anything that is mentioned as “the problem." This allows you to include multiple perspectives early on.

The goal is to quickly capture the information, avoid arguing and keep the investigation moving forward. Then, focus on how the incident has impacted your organization’s goals. By defining the problem in terms of your organization’s goals, you can minimize the unnecessary (and often unproductive) debate around defining the problem. To explore more on this, see one of my fellow facilitator’s blogs on How to Define a Problem.

Analyzing the Incident

If you’re already working on the analysis (in this case, building the Cause Map diagram), simply write down the volunteered perspective. It may be obvious where the cause fits, but sometimes it’s not. Remember, it’s OK to “park” the information to the side. By doing this, we can validate the person’s view and come back to it throughout the investigation.

As you build the Cause Map diagram, it’s important that you go into the necessary level of detail associated with the identified causes. Focus on the system of causes and not just one preconceived idea. The visual nature of the Cause Map diagram allows the investigation team to easily review the various causes that contributed to the incident. If someone is getting bogged down on one branch of the map, referring to the Cause Map diagram is a useful tool to keep the team moving, since it’s easy to illustrate that a different branch on the Cause Map diagram may be as important to analyze.

Exploring Possible Solutions

If the investigation focuses on the preconceived idea, the solutions discussed will only address one cause and, as a result, the number of potential solutions will be limited. In revealing the system of causes rather than focusing on a single cause, the number of potential solutions naturally expands. The more potential solutions available, the more creative and effective solutions that can be implemented.

As you find yourself facilitating an incident, listen and document the various perspectives and opinions that the team offers, it will only help reveal detail in the investigation. Just be careful not to let the loudest voice or opinion drive the investigation, as it will limit the purpose of the investigation as well as block potential solutions.

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