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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