Investigating in the Tunnel
In my experience, the biggest challenge for any investigator is to overcome the fears and mistrust of those involved in the incident. This is particularly the case where the potential for blame or finger pointing exists.
I was at an incident kick-off meeting recently where a senior manager announced he couldn’t understand why the guys hadn’t simply stopped the job before things went wrong. He proclaimed, “We have a great ‘Stop the Job Policy’, why didn’t they use it?” Of course, the reason they didn’t stop the job was simply explained…they had no expectation (unlike the self-congratulating manager with the benefit of hindsight) of an impending incident. I managed to hold my tongue, but such crass statements are so easily trotted out with the benefit of hindsight and can introduce unhelpful bias and destroy the investigation essentials…trust and truth, making it ok to talk about the reality of work!
No matter how strange or bemusing the actions or behaviours of those involved seem post incident, never prejudge and investigate through their eyes at the time. This is known as investigating `in the tunnel` as opposed to `out of the tunnel` with hindsight and outcome bias.
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