The Incident Investigation: Learning through Hindsight
February 2003
The construction industry is plagued with
too many fatalities and injuries which adversely impact families, business,
and the U.S. economy. Incident investigation can help preempt routine incidents.
This process involves the gathering data, analyzing that data, and transforming
it into action items for future use. Recognizing errors and failures and helps
prevent their recurrence, improves safety performance, and enhances productivity.
by Ron
Prichard, P.E. Ph.D.
Arcanum Professional Services
While there has been recognizable, industry wide improvement in construction
safety performance over the past decade, the industry is still plagued with
too many fatalities and injuries which adversely impact families, business,
and the U.S. economy. The truly unfortunate aspect of this is that, with the
proper application of available knowledge, this toll can be reduced. Armed with
the foresight of knowledge, the construction industry can preempt the occurrence
of routine incidents.
A powerful process for developing this knowledge exists: the incident investigation
process. The basis of this process, and its application in the field, will be
the subject of this article, designed to facilitate its utilization by owner,
contractors, insurers, and consultants.
Foundational Elements
For the majority of participants to the construction process, building is
a satisfying avocation, where professionals get to apply their skills, talents,
and expertise into the transformation of 2 and 3 dimensional plans and specifications
into tangible products. It brings great pleasure to those involved in building
to be able to step back and admire a completed facility and sell with pride
knowing that they had a hand in bringing it into being.
So, the objective is to get the projects built, and any distraction is often
viewed as an annoyance. Still, by coordinating such a diverse mix of parties,
often things are missed or overlooked due to the complexity and pressure to
accomplish challenging tasks in a dynamic environment. Incidents, such as property
damage, injuries, or even fatalities, are still far too common an occurrence.
"Accident" or "Incident"?
The incident investigation is one tool to assess failure, as manifested through
incidents of all types, on construction projects. The word "incident" is used
for a specific reason. Unlike "accident" investigation, "incident" implies the
need to investigate all negative occurrences, regardless of whether they result
in property damage or injury or not. Incidents rarely “just happen,” and they
nearly always leave clues that can be followed, as a trail of events leading
up to the incident. This is the power of the investigation, and the starting
point.
The word “accident” implies that the event was a fortuitous occurrence, a
mishap. It creates the impression that it just happened, and that it was unexpected
and unpreventable. This can create a means to escape responsibility, avoid rectifying
the situation, dodge scrutinizing current methods, and yield to pressure to
change. Unfortunately for those seeking to deflect change with the use of the
word “accident,” it simply is not a true representation of reality. My own analysis
of literally hundreds of these events in construction over the past 15 years
shows that a vast majority of the negative events that result in property damage
or personal injury are seldom fortuitous in their manifestation. This is a finding
supported by dozens of more rigorous scientific studies of “accidents” as well.
Incident investigation has been widely and long recognized as an effective
method for improving safety performance regardless of industry. The investigation
is a common element of all safety and health programs and a core element in
any safety and health education, be it formal or informal. So, if this is so
well understood, why is it so underutilized or inappropriately applied? It is
my belief that it is precisely the common understanding and widespread acceptance
that leads to its misapplication.
The Source of Misunderstanding
When everyone “knows” something, that something is burdened with a significant
amount of “cultural baggage,” and the “common sense” that ought to apply is
more conspicuous by its absence. What is commonly understood, and usually required,
is that in the wake of an incident, someone (or, routinely, everyone) in the
chain-of-command expects a report of some sort. In the classification of events
into minor (non-serious) or major (serious), the consequences or fallout of
the event is most commonly employed.
There are a whole range of steps associated with an investigation, based
on this classification, culminating in reports ranging from a simple one-page
brief narrative to a voluminous formal written report with a structured inquiry.
This range represents the “how” of the conduct of an investigation, and will
be the subject of a future article.
The conduct of the investigation, dictated by contract requirements or an
organization’s internal procedures (or both) has become a rule in construction.
It must be followed, or sanctions of some sort will follow. By transforming
the investigation into a rule, the original purpose and intent of imposing the
requirement is forgotten.
It is this element that has led to the codification of lessons from failure
in the creation of Occupational Safety and Health Administration (OSHA) rules,
industry consensus standards, and other means of defining proper approaches
to particular situations or conditions. The presence of an OSHA requirement
demonstrates that this is a commonly occurring situation, and that adherence
of the appropriate rules has already been shown to prevent injury. Yet, OSHA
rules are routinely ignored or skirted.
It is a common “rookie” mistake, when confronted with application of an organization’s
rules for the first time, to question the means and methods as prescribed by
the attendant task list. Inevitably, this leads to the rookie being chastised
for questioning the wisdom of authority and normally ends with a rebuke to “shut
up and just do what you are told.” Only the impaired or truly obstinate fail
to accept this requirement for survival. Individuals in an organization have
their performance judged by their compliances with the rules, not the achievement
of an underlying purpose of the rule.
The Purpose of the Investigation
There are several related purposes of investigations, all of which provide
benefit to an organization if properly applied. Each of these shall be addressed
in order of significance for the organization.
The primary intended purpose of an investigation has already been alluded
to. It is a method for an organization to learn and ultimately benefit from
the insight gained through that learning and its application to business methods.
If an organization doesn’t learn about negative events, then it is doomed. The
demise of an organization that fails to learn from its experiences is entirely
predictable—only the timing is open for speculation. When an organization, such
as a construction company, is in the business of reenacting its methods, the
significance of learning from negative outcomes grows. As they say, history
is bound to repeat itself.
The goal of an investigation is to direct the organization into a structured
process for learning. This process involves the gathering data, analyzing that
data, and transforming it into action items for future use. Recognizing errors
and failures and helps prevent their recurrence, improves safety performance,
and enhances productivity.
A second purpose of the investigation is to gather factual data to support
a successful recovery. This recognizes the power of knowledge. To adequately
defend itself and represent its interests, possibly against litigation, an organization
needs to know what happened, how, and why. The investigation, when properly
conducted, provides this information. It is a systematic effort that determines
what happened, who was involved, how it happened, why it happened, and what
were the indicators and points of possible intervention. This is all valuable
data for litigation.
A final purpose of the investigation is also defensive in nature. Investigation
can protect an organization and its members from fraudulent claims. By examining
the sequence of events and circumstances surrounding the event, the organization
protects itself by revealing the truth of the events. If an investigation is
not performed, there is no basis on which a misrepresentation can be refuted.
Lever or Club?
When an organization engages in an investigation for one of the stated purposes
above, the outcome is positive. However, as the purpose is frequently subsumed
in adherence to the rules, the purpose can become perverted through misapplication.
The fact of the occurrence of an event creates a significant benefit in conducting
an examination of what lead to it. This is commonly referred to as 20/20 hindsight.
The rearward look recognizes that while, at certain times in the past, decision
points presented themselves, and choices were made to proceed.
With the advantage of the clues, the historian, the investigator—or the plaintiff
lawyer—has the benefit of knowing what actually happened as a consequence of
the choices made at each decision point. Thus, in retrospect, the investigator
can decide how appropriate the choices were. This is where the learning value
is derived from an investigation. As the investigation uncovers truth, the process
of the investigation can be a “lever” to use to the advantage of knowledge and
hindsight to direct the course of future events in a more constructive way.
However, it is not always the case that tools will be appropriately utilized.
Unfortunately, the tool of the investigation can also be employed as a “club,”
with which people can be beaten up. This occurs when the focus of the investigation
is to affix blame, rather than to fix a problem. This can disrupt the application
of the investigation process as well. Too often, the burden of responsibility
and subsequent damages is hoisted on the scapegoat. This distorts the investigation
from an exercise in truth finding to a vehicle for pummeling and blame.
When this occurs, instead of being a mechanism for learning, the “lever”
is converted into a means of inflicting additional harm as a “club.” Those conducting
the investigation must adhere to its original purpose—as a learning process—so
that the organization, and those it serves, can benefit from the acquisition
of knowledge.
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