Whether you use TapRoot ®, ICAM (Incident Cause Analysis Method), Timeline and 5 whys or one of the myriad of other options as your weapon of choice in the hunt for the drivers of workplace safety incidents, the narrative remains the single most important element in your investigation report. What do I mean by this? The main tolls I use for serious incidents and fatality investigations these days are timeline and 5 whys, and ICAM – both modified to include consideration of Work-As-Done as it compares to how others do the work normally (Work-As-Normal) and how managers think the work is being undertaken as per the work instruction, procedure checklist or guideline (Work-As-Intended, or Work-As-Imagined).
I believe that simply creating a chart, identifying a couple of ‘root causes’ or a list of contributing factors does not cut the mustard in terms of maximizing learning and understanding of an incident. We need to also tell the story. After all, the investigation report is nothing other than the story of the investigation team’s version of the incident – how they see it through their eyes. Their story in other words. This is not ‘the truth’ anymore than an eyewitness’s version of the incident is ‘the truth’. It is simply another view of what happened and why. If we look at an event report it is not just one story or narrative, it is comprised of many narratives, often from different perspectives. These narratives come together in a well-written report to tell the story of the event. I was re-reading the Columbia space shuttle ‘Columbia Accident Investigation Board (CAIB) Report along with the ‘Columbia Crew Survival Investigation Report’ over the last few weeks and they are a classic exa mple of the many facets of an incident. Most of us do not have the resources or interest in the creation of over 600 pages of report (And that only includes Volume 1 of the CAIB report and the crew survival report), but we do have the resources to pull together the various stories of an event in such a way as to make is accessible to others. By the way a great book to tell the various stories of the Space Shuttle Columbia tragedy is called Comm Check… The Final Flight of Shuttle Columbia by Michael Cabbage and William Harwood, published by Free Press in 2004.
Let’s look at an example of an Organizational Factor from an investigation that is a bit closer to most of us than a Space Shuttle: Firstly from the ICAM Chart in the report: “No link between training and fatal risk database”, and secondly from a possible narrative associated with it: “There is no formal link between the ‘Training and Competency Development System’ and the site’s ‘Fatal Risk Database’. As the ‘Training and Competency Development System’ drives the creation of the ‘Training Needs Analysis’ and the ‘Training Needs Analysis’ dictates, amongst other things, what goes into the site’s induction, when the Induction was recently changed and the working at height section was removed nobody recognized that awareness around work at height was essential for all employees and contractors who may be exposed to the risk and that it had gone from the induction. Apart from any Management of Change issues which are discussed elsewhere in the report, it was the underlying lack of a formal link between the ‘Training and Competency Development System’ and the site’s ‘Fatal Risk Database’ that ultimately drove this omission.”
One tells the story and the other forces us to think about what it is saying, build our own story and perspective about what it says before we can make sense out of it, understand it and learn from it.
To sum up, we all like to hear stories. They apply colour, perspective and life to mere facts. We learn from stories. We remember stories and we use them to share and engage with others. Use this in investigation reports and you will go a long way to helping understanding and learning.