Serious incidents – are the lessons being learnt?

By Dr Torkel Soma, SAYFR

SAYFR tools: Preparing leaders as role models for behaviours that over time create an atmosphere for employees to speak their mind (illustration: SAYFR)
SAYFR tools: Preparing leaders as role models for behaviours that over time create an atmosphere for employees to speak their mind (illustration: SAYFR)

Often the only good thing that comes out of a tragedy or disaster is that the investigation gives us some knowledge of how to prevent similar incidents in the future. But are we learning as much as we should from these incidents?

After all well-known incident investigations have over time received massive criticism. A review of several investigations summarises four main areas of criticism that lead to the conclusion that perhaps there is more to be learned and given the sensitive and important role incident investigations have in developed societies, it is crucial that these four areas will be given attention going forward.

The four areas of criticism are as follows:

1. Alternative causes not sufficiently addressed
In a series of high-profile incidents, the survivors, and the bereaved have struggled to find the peace of mind and the reconciliation that would allow them to move on with life. A common trait is that they are not convinced that the investigation sufficiently addressed, or ruled out, alternative causes or chain of events.

There are many examples from around the globe including several here is Scandinavia including:

  • Scandinavian Star: Could the fire be a result of insurance fraud?
  • Estonia: Could the loss of the bow visor be caused by an explosion or was there a collision prior to the capsize?
  • Could the lost fishing vessels Utvik Senior and Western be caused by collisions rather than weather and stability problems?
  • Were there additional causes behind the loss of the leg causing Alexander Kielland to capsize?

It may well be that the investigation was correct in its conclusion but when such questions are still asked and unanswered several decades after the initial investigation, it demonstrates that the investigations have not sufficiently met the needs of all stakeholders.

2. Doubts over independence
Incident investigations put “checks and balances” to the test. A basic principle is to distinguish the incident investigation from criminal procedures. But still an investigation report may be used to place responsibility and blame for the incident so it imperative that the investigation team is a neutral independent party.

It is worth noticing that an external investigation cannot automatically be seen as “neutral” and “independent”. Concerns about their own business relations and service offerings may influence what and how the investigation proceeds. Even public investigations may not always be seen as “neutral” and “independent”. To ensure maximum neutrality, the composition of the investigation team should also be given thought to make it diversified and multidisciplinary. There are some key characteristics of investigation reports written by teams having questionable independence:

  • Often the sequence of events leading to the losses are described but do not sufficiently address the causes behind these events.
  • Causes are described as deviations, non-compliance, and failures done by the people at the scene, but do not thoroughly explain why these people made the deviations or failures.
  • Root causes are not thoroughly investigated.
  • Sometimes the conclusions are delayed until others have done their investigation.
  • Low interest in additional data sources or interviewee candidates.

Some of the notable cases where this has occurred include the Rocknes grounding (2004), Costa Concordia (2012) and most recently the Roald Amundsen COVID incident in 2020.

All these characteristics drive attention away from real underlying systemic causes and push blame towards the few individuals involved in the incident. Even the decision to investigate or not is also highly sensitive. In several major incidents, it has been decided not to do an incident investigation. The argumentation of those decision-makers often uses the same characteristics as listed above.

3. Culture and human factors not systematically analysed
It has long been recognised that most incidents involve human and organisational causes and attempts have been made at various times to develop a system that deals with this complex field. During the 1970s and 1980s various types of “inadequate tasks” were used in accident investigations. When a ship collided, the investigation often concluded that a cause was “Inadequate lookout”.

It was however recognised during the 1990s that reference to the failed “task” did not provide adequate learnings, and the attention shifted towards systemising different types of “human failures”. Examples are “slip” when somebody pushed the wrong button, “lapse” of memory or intentional “violation”. But this approach proved also to be ineffective. However good the categorisation of different types of “human failures”, the root cause for the failures is not addressed.

Early in the 21st Century attention drifted away from general tasks and failures to focus specifically on the safety barriers. Bow-Tie and Swiss-Cheese diagrams were frequently used to describe broken safety barriers and how the awareness of these barriers will make a difference. Then the Macondo accident took place in the Gulf of Mexico in 2010. This accident demonstrated that it does not help to be aware of safety barriers if you deliberately choose to bypass them.

The learning from the Macondo accident (among others), set a new course with the “Local Rationality Principle”. This concept implies that the people involved in incidents acted as they did because it made sense for them to do so. Hence, instead of systemising the task, failures, or barriers, the ambition shifted towards explaining why the people involved believed they were doing the right thing when they were in fact doing just the opposite.

During these years, the safety regimes within space, aviation, and energy sectors have led the way. The investigation into the space shuttle Columbia disaster in 2003 was ahead of its time and is among the few most thoroughly investigated disasters. The investigation recognised the flaws in conventional investigation techniques and chose a different approach. Namely, to evaluate if traits of very mature organisations could be seen in NASA. This way they revealed the root causes highlighted in their conclusions.

The various developments close in on how organisational culture shapes safe behaviour. We know today for example that the need for Trust, Care, and Openness are foundational abilities that must be in place for mature collaboration to take place. When this foundation is in place it allows for Learning, giving Feedback, Speaking-up, Teamwork, and managing Dilemmas. Currently, this knowledge on how to handle human and organisational causes is a professional expertise and there are no general scientifically proven and accepted methodologies to systematically map out these underlying causes at scale.

4. Overcoming obstacles to learning from investigations
An incident investigation report provides insight into the chain of events leading to the incident and the causes behind it. But the real learning from the incident occurs when this insight is transformed into real improvements that prevent the re-occurrence of similar incidents. There are huge challenges in effective learning. There are some assumptions that need to be in place if an organisation will learn from an incident investigation report:

  • There is a need to improve and learn.
  • The causes in the investigation are also relevant for this organisation.
  • That colleagues will support the changes.
  • No negative effects from this learning.

It requires some maturity to answer these questions in a correct way. Hence, it is often the less mature organisations that do not have these assumptions in place. This is an initial barrier to learning. The second learning barrier is to address the root causes rather than the symptoms of these causes. Learning topics that fit in the format of a task list is often prioritised. It is for example much easier to update a procedure, than to create a culture of compliance. Hence, learnings that heal the root causes fall on the backburner.

Conclusion
The four main areas of criticism lead to the conclusion that perhaps there is more to be learned and given the sensitive and important role incident investigations have in developed societies, it is crucial that these four areas will be given attention going forward.

“Sharing of mistakes and failure has a massive potential for an organisation in terms of learning, innovating and reducing risk of serious incidents” – Dr Torkel Soma is Chief Scientific Officer at SAYFR
“Sharing of mistakes and failure has a massive potential for an organisation in terms of learning, innovating and reducing risk of serious incidents” – Dr Torkel Soma is Chief Scientific Officer at SAYFR