I think anyone connected with safety or mishap investigations needs to rethink why we do investigations, rather than blindly accepting the folk wisdom about investigation purposes. I suggest that purposes like "to prevent recurrence!" or "find the cause or probable cause or root causes" or affix blame or find out what happened and why or find lessons learned or settle claims miss the ultimate purpose, and misdirect investigation practices.
I'd offer this simple candidate: TO CHANGE BEHAVIORS. The reason for investigating an occurrence is to find, understand and report the behaviors that produced an unwanted occurrence, and their context, in a way that others engaged in similar behaviors can learn about them and apply that information to their future activities.
I would argue that this purpose would change how investigators do investigations and what they produce, by focusing their inquiries on what people, objects or energies did during mishaps, and why they did that. I would argue further that this would improve future investigation efficiency, efficacy and value. I would also argue that this would produce better predictive understanding of mishap phenomena if it were applied to present system safety analysis practices.
Anyone want to defend the status quo?
4 comments:
I respectfully disagree. The purpose of INVESTIGATION is to IDENTIFY behaviors, not to change them. Once the behavior that has led to the undesired outcome has been identified, then it is the responsibility of the affected systems' managers to change it. As Dekker has stated, undesired outcomes are products of normal people doing their everyday jobs as best they know how. If undesired outcomes happen, they are the result of behaviors that had not been anticipated and accounted for in original concepts & designs.
I suggest this is a short sighted view of investigation purpose. Why bother if it does not actually produce changes needed?
As to managers responsible for changes argument, I submi that this view reflects a regulatory/control everything mindset. Managers do not nor can they define and control all behaviors, especially in complex systems; for example, consider unforeseeable changes, hidden defects, or interactive timing or sequence related other surprises to which individuals must adapt. Managers are not gods.
And that's not how I read Dekker. Maybe we should get him involved
Grumpy has left a new comment on your post "Kickoff blog 1":
One must have the ability to CONTROL BEHAVIOR in order to CHANGE BEHAVIOR. Few investigators have that authority. Current investigatory practices have been proved unable even to identify sources of "error" effectively, so why in the world would you want to give them authority to instantiate behavioral change?
Who says managers are gods? They are the ones who screwed up in the first place. But in current systems they are the people in authority. If you choose to cut them out of the process you substitute anarchy. Get real!
Grumpy's comments seem to reflect a misunderstanding of my argument, which I may not have stated clearly. Investigators don't bring about change - investigations are just one element of a lessons learning system - the element that supplies the behavioral data on which needed changes are based. For change to occur those data must find their way into the hands those who can recognize and implement the needed changes, in the context of their activities. They could be managers, designers, operators, supervisors, procedures writers, regulators, insurors, inspectors, or any of the many individuals with tasks involving the identified behaviors.
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