Should the RCA Team Include the Person Involved in the Incident?

When something goes wrong, root cause analysis (RCA) investigation facilitators know that they need to talk to the people with first-hand knowledge of what happened. The people involved in an incident are a critical resource in every investigation. However, it can be challenging to determine exactly what role they should play.

There’s a spectrum of ways to include an incident-involved person in an investigation, from a single interview to full membership on the RCA team. Here are the guidelines and factors I use to navigate this complex decision for each unique incident.

Interview the Incident-Involved Person As Soon As Possible

At minimum, the person involved in the incident should be included in the investigation as an interviewee. Evidence is perishable, so talk to the person as soon as possible. I recommend conducting a one-on-one interview with the person even if they’ve already submitted a written statement or told their supervisor what happened. People often leave details out when they write, and supervisors may also forget details or introduce bias (error) in their retelling of the incident.

Interview the incident-involved person in a private, quiet setting. Let them know that the purpose of this interview and the overall investigation is to gather the facts about what happened—not to blame or punish people. Ask open-ended, non-judgmental questions. For example, instead of asking, “Why did you open the wrong valve?” you could ask, “Can you walk me through the steps you took before opening the valve?”

Keep your Cause Mapping^® file open during the interview. I recommend taking notes and updating your analysis within the file, rather than creating new documents. During the interview, it’s often helpful to pull up your draft Cause Map™ diagram to provide a visual point of reference for the conversation. Even after the person has “told you everything,” looking at the Cause Map diagram often prompts them to share additional details.

Stay Connected With the Person

It’s wise to keep communication channels open after the initial interview. If the incident-involved person remembers a forgotten detail or has a solution idea, you want them to share it with you. You may also want to re-interview the person if new information comes to light. So, if it’s possible, share your contact information with the person and ensure you have a means to reach them. A direct line of communication is often the most effective.

A good moment to reconnect with the person is when you’ve completed your analysis and started to identify solutions. They are closest to the work, so they can come up with solutions that supervisors and SMEs may not see. Additionally, involving them in identifying solutions can build their buy-in for playing a role in implementing those solutions. The unique insights of incident-involved people often lead to more practical and effective solutions, and their involvement can enhance the overall success of the implementation process.

Weigh the Pros and Cons of Adding the Person to the RCA Team

There’s a big difference between including the person in the investigation vs. including the person in the RCA team. Including the person in the investigation means you’ll pull them as a resource when needed. Adding them to the team sets the expectation that they’ll participate throughout the investigation, join multiple group meetings, and contribute every step of the way.

In my experience, incident-involved people are typically not added to the RCA team. There are legitimate reasons for this, such as a lack of availability and concerns about re-traumatizing the individual. However, there are also less legitimate reasons, such as the belief that the person is biased. It’s important to remember that everyone has biases, including the person’s supervisor, the supervisor’s supervisor, and the investigation facilitator. Don’t let fears of “bias” allow the RCA team to shut the incident-involved person out of the investigation entirely, or you’ll miss out on crucial insights.

While it’s not common to include incident-involved individuals on the RCA team, it can be helpful to think through the potential advantages. Their first-hand knowledge can add critical details and clarify misunderstandings that arise throughout the investigation. Additionally, the individual can learn by participating in the investigation process and gaining a deeper understanding of the incident's causes and the measures needed to prevent future problems. This involvement can also build their buy-in for implementing the solutions identified, making them valuable advocates for change.

Beyond these pros and cons, I recommend considering three additional factors:

1. Organizational policies: If organizational policies state that those involved in incidents should not be included in investigation teams, it’s best to follow those guidelines.
2. Team dynamics: Consider whether the person’s participation in group meetings may influence what they and others say.
3. Sensitivity: Including incident-involved people can make it challenging to maintain confidentiality in sensitive, high-stakes investigations.

Remember, RCA Team Composition Can Evolve

Deciding whether to add the person involved in the incident to the RCA team is never an easy decision. Fortunately, though, you don’t have to decide whether to fully include or exclude the person from the team right away.

We recommend an iterative approach to building and managing the RCA team. This way, you can follow up one-on-one throughout the investigation, and even pull the person into some meetings that are appropriate but avoid the issues that can arise with including them in every single meeting. Balancing these factors will help you create a flexible and effective investigation team.