Despite the best efforts of everyone involved, sometimes things go wrong within a business. To determine whether this is through human error or a system that doesn’t fulfil its role completely, will often require an incident investigation. Organising one of these investigations requires specialist knowledge and training to avoid a repeat in the future, or to highlight a system or procedure that doesn’t work as designed.
What is an incident investigation?
An incident investigation is a term used to describe a series of steps in a process that look into the incident in order to determine the underlying causes. While it isn’t about assigning blame, this can help identify if someone is found to have done something outside the rules or processes that are in place that led to the incident. Effective incident investigation techniques can fulfil health and safety requirements, as well as accountability issues for shareholders and senior management.
Beginning the investigation
Depending on the nature of the incident and the business involved, there may be some immediate action required when a problem is highlighted. Examples of this include making an area safe while preserving the scene for those looking into the problem, allowing them to study it as a part of the investigation. If relevant, perishable evidence should be collected as quickly as possible – such as CCTV recordings that would be automatically wiped unless the recording is saved.
Planning the investigation is one of the most crucial steps for success. It should involve appointing one or more people who head the investigation, and assigning any resources to them that they may require. A timetable for the investigation should be laid out, with the possibility for extensions if the situation dictates. It should also be settled what investigative tools and models may be used as part of the process. Also important is to make sure that the scope of the investigation is fully understood by all parties concerned.
Data collection and analysis
Once the framework for the investigation is in place, work can begin. Collecting data can involve talking to people, collecting computer evidence, CCTV footage, documentary evidence and equipment in use at the time. All of this should be documented during the process to ensure that the results can be verified by an independent source, should this be required.
Creating a comprehensive chronology of the incident begins as the data is being collected. Each element is a piece of the puzzle and the investigators put these together to gain a full picture of what happened. Analysis of the information gathered can take some time but should be done thoroughly.
Finding the root cause
One of the central aims of the analysis of the collected data is to find the root cause of the problem. There are different ways to do this depending on the situation. One example is the Fishbone or Ishikawa Design, also known as the Cause-and-Effect Diagram. This uses a number of categories to identify the cause of the problem, including methods, machines, people, materials, measurements and environment. These causes lead into one another, with the question of ‘why does this happen?’ being central to the process.
Another example of a system used by incident investigation teams is the ‘5 Whys’. This process takes the basic incident and asks a series of ‘why’ questions, each leading to another ‘why’ question. The eventual answer will be the root cause of the problem.
Human error is often a term used to cover a multitude of problems and situations, but rarely are people willfully negligent. As a rule, the human error theory looks at influencing factors that led to the mistake occurring, such as the mental or physical abilities of the person, or the management systems of the business.
Finishing the incident investigation
Writing the investigation report will be done to the format decided at the beginning of the investigation and will usually involve the corrective actions that are required to prevent a reoccurrence of the event. It may be delivered in a number of ways, such as at presentations and meetings, as well as formal and informal incident investigation reports.
Some measures may be short term and quick to implement while others may involve institutional changes over a longer period. Sometimes, reports can highlight other potential problems that have been discovered during the investigation that have the same root cause.
The reporting of the investigation may also use SMART recommendations – specific, measurable, achievable, relevant and time scaled. This creates a framework for the changes needed going forward, ensuring they can be completed and what timescale they need to be completed within. It also creates a system to measure the changes to ensure they work in practical terms going forward.