Latest / Safe As Podcast / Ep 5: What you find in investigations isn't what you fix

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Ep 5: What you find in investigations isn't what you fix · Safe As Podcast

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  We investigate, we analyse and we identify contributing
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  factors. Then we recommend fixes.
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  Simple right? Or is it our investigations such
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  as the truth or more a game of socially negotiated whack, a
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  mole influenced by competing socio political influences?
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  Less about fixing issues and more about systemic pressures
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  and biases shaping what factors we construct, find or dare to
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  find. Let's explore how aspects other
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  than causes influence what we find and fix.
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  Good everyone. I'm Ben Hutchinson and this is
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  Safe as a podcast dedicated to the thrifty analysis of safety,
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  risk and performance research. Jump onto safetyinsights.org.
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  More research. Today's study is one of my
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  favourites titled What you find is not always what you fix how
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  other aspects than causes of accidents decide recommendations
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  for remedial actions by Lundberg, Roland Hagen and
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  Hornagle published an accident analysis and prevention in 2010,
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  so for methods they interviewed 22 accident investigators to
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  understand the hidden constraints that pull
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  investigations away from the ideal assumption.
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  What you find is what you fix. In essence, how does the same
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  organisational context that contributes to accidents also
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  constrain the investigation process, shaping the causal
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  factors that are identified for mediation?
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  So what do they find? While investigators believe that
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  they followed the what you find as what you fix ideal, the data
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  showed that analysis and the design of actions are heavily
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  influenced by practical constraints.
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  As the authors put it, this results in the reality that what
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  you find is not always what you fix.
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  There's too much to cover in this paper, but here's a few of
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  the key findings. What you fix depends on what you
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  can understand. This relates to the
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  investigator's experience and their knowledge of the task.
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  This constrains what they can actually find and fix.
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  What you fix depends on what you can afford to investigate.
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  Resources and time are major limitations.
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  What you fix depends on what you can find.
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  Investigators struggle to speak with all of the relevant
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  stakeholders, especially outside of their own company.
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  What you fix depends on what you dare to find.
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  Management isn't always open to criticism, which can hinder
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  examining management influences, echoing findings from major
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  accidents like the NASA Challenger shuttle disaster.
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  What you are able to fix depends on what you find or when you
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  stop looking. Investigations often stop based
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  on arbitrary stop rules, like ticking off all the facts or
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  identifying a set number of fixes, or stopping where you run
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  out of time. They do this rather than a
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  comprehensive understanding or deep dive.
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  What you know how to fix is what you fix.
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  Investigators might gravitate towards problems with known
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  remedies, even if more complicated but effective
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  strategies exist. This can lead to fixing what's
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  easy, not necessarily what's best.
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  What you fix depends on what is easy to understand and known to
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  work. This prioritises readily
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  available solutions and established rules, even if
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  they're not the most targeted or suitable for that context.
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  What you fix depends on what you're going to fix anyway.
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  Sometimes investigations simply validate preconceived fixes or
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  fixes that support their existing worldviews.
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  So we find and fix things we were going to find and fix
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  anyway. What you fix depends on what
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  someone else decides. Recommendations may be overruled
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  by higher ups and those with power, but also by people who
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  might actually lack direct familiarity with the issues.
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  And what you fix depends on the cost benefit balance.
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  Despite claims for the contrary, cost often influence the types
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  of actions taken, sometimes leading to less expensive
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  temporary fixes. So there's a bigger picture.
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  The authors argue that while thorough investigation methods
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  are still useful, they're unlikely to prevent most of the
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  factors mentioned by these investigators from leading the
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  investigation away from that ideal of what you look for is
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  what you fix. Said differently, these
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  influences are at play in all investigations, regardless of
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  the methods used. You might think that you're
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  immune from these issues, or that using method A isn't
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  susceptible, but these sorts of factors in some capacity in
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  configuration likely exist in all investigations.
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  Interestingly, no investigator blamed poor investigation
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  methods as a constraint. Instead, they highlighted these
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  external and internal pressures. This suggests that Acts
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  investigation isn't purely rational, nor is the choice of
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  actions. Perhaps, as the authors
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  pragmatically suggest, it is actually irrational to consider
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  the possibilities and constraints of a situation when
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  selecting fixes. Also, it's not necessarily based
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  on flawed thinking. Many of these constraints are
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  sociopolitical, not cognitive biases.
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  So what can we make of this? Besides the obvious of
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  considering investigations as socially negotiated activities,
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  another implication is how we treat the findings.
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  If we see investigation findings as simply some areas for
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  improvement, then happy dance. But if we see them as purveyors
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  of reality, confirmation that our systems are working and risk
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  are acceptable, then I think we really need to reconsider.
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  Paraphrasing Andrew Hopkins, bad news doesn't travel well.
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  So what were some limitations? Of course, with just 22
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  investigators, sample size is always a consideration when
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  considering. How generalizable are the
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  findings? However, other research does
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  support the investigations are indeed affected by various
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  socioolitical influences. That's it.
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  On Safe as I'm Ben Hutchinson and hoe you found this useful.