Performing an Effective Incident Investigation

I am commonly asked by clients to participate in or review the thoroughness of an incident investigation. Based upon my experience, many of these incidents are incomplete and fail to accurately satisfy the objective: identify the actual root cause(s) to prevent a similar future incident. Listed below are some of the major shortcomings I have noticed with incident investigations:

1. Failure to identify the real root cause(s): Incident team members sometimes don’t utilize an effective investigation method, such as TapRoot, Failure Mode and Effects Analysis (FMEA), as well as many other equally effective investigative tools. This results many times in incomplete analysis which identify symptoms but not the underlying root cause(s).
2. Lack of team Expertise: The team may not be comprised of the necessary technical expertise to perform a thorough incident analysis. Has the team leader assembled the necessary personnel to perform the review? This may include an electrical engineer; an electrical & instrumentation specialist; a metallurgist; etc. Assembling a complete investigative team reduces the likelihood of overlooking potentially critical evidence.
3. Confirmation Bias: This occurs when the team or a team member reaches an early conclusion to the root cause and only considers evidence supporting it. Other critical evidence may be ignored potentially resulting in an incomplete investigation.
4. Normalized Deviation: A simple way of restating this is seeing something wrong for so long you accept it as correct. When performing an incident investigation, it is paramount that you review work practices and compare them against standardized acceptable practices. In many cases, a company has established work practices but they are not followed. To determine if normalized deviation has occurred, it is sometimes beneficial to assign a team member from outside the immediate incident area. He/she may ask very elementary questions as part of the investigation that identify a significant problem.

This is by no means a comprehensive list but is intended as a tool in assisting you in performing effective, thorough incident investigations.

Jon

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