Investigation is pretty much all I've done all my adult professional life.
My passion for striving to discover why things went wrong has never diminished. As a career detective my motivations were simple: find out who was responsible for the crime, gather the evidence and present them to the courts. Job done and onto the next call.
At the end of this exciting career, I moved into the world of industry incident investigations and it was indeed a whole different world. Having started up a niche incident investigation consultancy, I was beginning to realise that my investigations had to be viewed through a very different lens.
Clients would say “what we have here is a blame free culture. What we need to do is make sure we learn from this incident and avoid repeat failure”. Aahaah, how refreshing I thought.
Having investigated too many murders and awful events in my police career, it occurred to me that very rarely did it matter to me why the individual had committed the crime. Yes, of course motivation was always of interest, but understanding the socioeconomic reasons behind such a crime were of limited concern. In other words, it was all about the what not the why. That’s changing by the way and that’s a good thing!
A while back, I presented at a conference (remember them) on the theme of learning from incidents. I used the tale of the Emperor’s Clothes as the moral thread. Every organisation I've encountered professes to have a blame free culture with `learning at its heart` but is that really the case and if not who's kidding who?
In the same way as the emperor was being fooled by his people, are Leadership Teams being similarly hoodwinked?
During the coffee break after my presentation, a Group HSEQ Director from a large and well-respected organisation introduced herself to me.
“Why” she lamented, “is it only when something goes wrong, that we conduct an investigation? Everyday, most of our people get most things right most of the time but it’s only when they have a lapse or a failure that we switch on the flashlight.”
Every now and again in life, someone says something that makes you stop and really think. It can also make you feel a little bit foolish that you haven’t seen it for yourself.
I call this a “bleedin` obvious” moment. I've had a few but let me recount my first. During investigation training, when teaching how to develop effective preventive actions, I regularly give the example of a young police officer being shown his new `beat` by his sergeant (me). He was being introduced to a notorious winding stretch of road, in a rural location, where fatal traffic accidents were all too frequent.
Cars slid off the road with monotonous regularity and struck roadside trees. “We've tried everything” said the sergeant. “Safety campaigns, friction increasing surfaces, speed cameras...but still people get killed”. Without what seemed like a second thought the young officer said, “Why don’t you just remove the trees?”
I suddenly felt very foolish, but he was right. Decades later the winding road is still there, and cars continue to slide off the road, but the trees have gone as have the fatalities. What a learning moment for me but as the young officer said it’s “bleedin' obvious”.
So back to the conference. The HSE Director had provided me with yet another “bleedin' obvious” moment: why do we limit learning opportunities to simply investigating infrequent failures when there are so many wider opportunities to learn from success?
And so, my journey as a career investigator has taken another big learning step. As a Detective it was all about what happened, then as an industry investigator it was also about understanding why it happened. Moving forward it has to be about both the what and the why but also the when.
For organisations to capitalise on learning opportunities, when an investigation is initiated has to extend beyond the trigger of an incident or unplanned event. It has to get into the space of everyday work and learn from what is done well most of the time.
In a similar context, most organisations perform an internal audit day in day out across the business. But let me pose this question: what do they actually learn? Identifying non-conformance is important but that’s simply the what. Where's the why?
I work at the heart of developing an investigation and root cause analysis model called COMET. It's a project of passion but it’s a never-ending journey. What is it we say about learning? Every day's a school day!
The next exciting challenge for the COMET team is to accelerate its next-generation development into proactive understanding and learning, and we are well on the way.
There will always be a place in organisations for orthodox reactive incident investigations and root cause analysis. Not to do so would be foolhardy.
But imagine having an investigation process that includes internal audit & everyday work analysis, to proactively show root causes before they came home to roost. Now that’s `bleedin' obvious!
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