Following a fascinating career in law enforcement, my transition from being a criminal investigator to an industry investigator was both challenging and rewarding.
As a career detective, I worked in an environment where the sole objective of the investigation was to identify who was responsible for a particular criminal act and bring them to justice. In other words, who was to blame?
Rarely was it the remit of the investigation to attempt to understand why the perpetrator committed the act but simply prove what wrong they did.
Understanding the ‘why’
© Supplied by COMETOf course, this is the critical difference between these investigation types, as without understanding the why, you cannot apply the fix. In criminal investigations, there are few options to “fix” other than imprisonment.
The societal objective of the prison system is to rehabilitate offenders and turn them into good citizens, however, for those within the system, it is viewed simply as punishment.
This attempt to “fix” the individual in the prison system has an unsurprisingly low success rate, estimated at less than 3%. However, in embracing the world of industry investigations, I have spotted interesting parallels.
Human error is an inevitable component of most incidents, and despite most organisations subscribing to a “blame-free” culture, time and time again, I continue to see preventive actions disproportionately focus on “fixing” the worker.
Let’s undertake further training to improve competence, create more comprehensive procedures to adhere to, and increase supervision levels to ensure compliance.
Sound familiar? I’m not suggesting that such actions have no place. However, there is a futility in obsessing to influence individual behaviours when, all too often, the organisation or systems in place, lacking human error resilience, are the real offenders.
Investigating human error
In almost every investigation I have conducted, and there have been a few, human error has been a feature. Some poor, well-intentioned souls will have done something they ought not to or failed to do something they ought to.
It would be so easy to close out an investigation with a focus on an individual’s shortfall, however, that would not only be an investigation shortfall but also an organisational shortfall.
A clever man once wrote: “Mistakes arise directly from the way the mind handles information, not through stupidity or carelessness. Attributing incidents to human error is about as useful as attributing a fall to gravity.”
At the moment in time a human error occurs, you can be certain that the individual involved thought they were doing the correct thing. As an investigator, if you can get to an understanding of what performance factors influenced the error, you’ve cracked it!
© Supplied by COMETFrom individual to systemic issues
During such investigations where human error is a factor, I always apply a technique known as the “Substitution Test” – it’s really simple but very effective in understanding what influenced the error.
Imagine you substitute the individual who erred with a co-worker competent in the same task. Then, pose the question: “Is it possible that had the substitute been performing the same task, the same mistake could have occurred and resulted in the same outcome?”
If (as is almost always the case) the answer is “yes”, then it confirms this is not an individual issue but something broader – systemic or organisational.
Therefore, the focus of the investigative effort and improvement ought to be on what was missing in the system, process, or management that failed to “catch” that inevitable human error.
The COMET RCA Philosophy promotes human error as an organisational learning opportunity. It is the only system worldwide with a fully accredited integrated Human Factor Analysis component.
This is the approach that will enable you to focus on fixing the work, not the worker!
Make sure to stop by COMET’s stand at this year’s Safety Expo on the 19th of September.
Don’t miss Alan’s speaker slot: “Avoiding the finger of blame – Understanding the opportunities Human Error brings in Investigations”.
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