Incident investigations are a critical component of every comprehensive safety and health management system. When viewed as a process and from the perspective of a learning opportunity, they can support, enhance and aid in the continuous improvement of the existing safety and health system. Too often however, they are associated with negative consequences, a faultfinding approach whose sole purpose is to place blame and to hold individuals accountable for causing the mishap. The purpose of this presentation is to challenge how safety and health professionals and leaders manage incident investigations. To shift they're thinking of incident investigations being event driven to that of a process, continually being improved upon and modified. Furthermore, to bring to the forefront the relevance and applicability of recognizing the incident investigation as an interpretive process, one that requires both investigators and leadership to be fully engaged and open to the learning opportunities that are disclosed.
To examine incident investigations from a process perspective recognizes that there is a systematic approach to looking at a mishap, with each step of the investigation connecting with the next. No one step is more or less important than the others, and each must be systematically developed and explored. The investigation process has built in feedback loops to determine how the process is functioning. More importantly, the investigation process can be continually improved upon. When viewing incident investigations from a process perspective, it is important to keep in mind that they are one piece of an entire safety and health system. The information learned from the investigation must be continually feed back into and understood within the larger safety and health system.
Interpretation is the process by which people come to an understanding, exploring their deeply held beliefs and historical pre-conceptions in light of new information and the limitless possibilities they hold. Rather than simply explaining the facts and events of a mishap, an interpretive approach offers safety and health professionals and leaders the ability to fully explore and clearly understand how the various causal factors came into being. This process of understanding then allows for the development of long-term and sustainable corrective actions. Thus providing for and ultimately improving the overall safety and health system. safety and health system.
While there are various investigation designs to select from, for the purposes of this paper Ted Ferry's (1988) 12 steps of a through investigation will be used. According to Ferry (1988: 241), "one finds that the 12 steps are not that clear-cut and readily separated. When a mishap occurs, the steps run together, overlap, and are carried out simultaneously." He continues, "[t]his overlapping process need not dismay the manager. If he knows what each step involves, he can still be certain that each one is properly carried out, wherever it falls in the sequence" (1988: 241). The remainder of this paper presents each of the steps, describes its intended purpose, illuminates the process opportunities, and illustrates how an interpretive orientation is evident.
