Incident Safety Investigations: Who Should Lead Them?

“Every man is guilty of all the good he did not do.”  — Voltaire

Early in my career, our boss assigned a colleague and me to investigate an incident that was still having a significant impact on the plant. Being an arrogant know-it-all, I mean, an engineer, I was confident that I already knew what the cause was. My colleague was equally confident in a different cause. He proposed a wager, at which point our boss stepped in.

“No bets. I want the two of you to approach this with open minds, find all the facts, and follow them wherever they take you. If you’ve already bet on the outcome, you’re going to be interested in finding facts that prove you’re right than in finding the truth.

“I mean it. No bets. I will fire you both if I hear that you did anyway.”

Most of What We Know About Investigations is Wrong

That was an important lesson, but I still had a lot to learn. And to unlearn. That’s because most of what people “know” about investigations is what they learned from the movies and television shows. The point of movies and television shows, however, is to tell a compelling story, with conflict, character development, and a narrative arc. It is not to show how an incident investigation is done.  Worse, movies and television shows featuring investigations are mostly devoted to investigations of crimes.

Why does that matter? It matters because criminal investigations, like regulatory investigations, civil investigations, and insurance investigations look for whether a law, a regulation, or a contract was violated, and if so, by whom. In other words, they are concerned with blame for something that has already happened. They are backward looking.

Safety investigations, on the other hand, are forward looking. They are interested, not in who is responsible, but in what is responsible. That is because the purpose of a safety investigation is to find out why an incident occurred so that it can be prevented from happening again. A safety investigation that does not result in recommendations to prevent recurrences is useless. This approach will save lives, but it doesn’t make for particularly good storytelling.

Who Should Investigate an Incident?

Safety investigations require several roles. A chairman, to lead the investigation. A scribe, to record and organize the data—the facts—that the investigation assembles, as well as its assumptions and conclusion.

An interesting note about facts, assumptions, and conclusions: While facts, assumptions, and conclusions may each be true, the truth of a fact is not altered by additional facts. Assumptions and conclusions both may need to be adjusted with the discovery of additional facts.

A safety representative, someone who understands the principles and regulations governing safety. Representatives from the involved department, people who understand how things are done in the area where the incident occurred. An independent party, someone who does not have a personal stake in the outcome of the investigation, whose only interest is improved safety.

One person may fill more than one role. Likewise, it may take more than one person to fill a single role. It is very unlikely that a single person can fill all five roles, which is why OSHA insists on investigation teams in the Process Safety Management (PSM) Standard (29 CFR 1910.119(m)(3) ).

Who Should Lead an Incident Investigation?

Some will insist that chairman of the incident investigation team, and for that matter, every member of the team, must be objective. In 1986, Thomas Nagel wrote a book called The View From Nowhere. He argues that true objectivity is not possible, that true objectivity is a “view from nowhere.”  Instead, he argues that everyone draws from their own experiences and biases. This includes investigators and witnesses. So instead of objectivity, which is not possible, what we need is a team that is aware of their biases and prepared to compensate for them. Likewise, we need multiple witnesses, so that biases can be offset.

The chairman of the incident investigation must be someone who can master their own biases, as well as recognize and compensate for the biases of others involved in the investigation. Everyone involved should have an interest in the investigation, so far as it leads to preventing recurrences of the incident. If other interests outweigh this, such as interests in personal or organizational reputation, in fixing blame, in quickly getting production going again, in controlling costs, or in winning a bet, then those other interests disqualify someone from leading an investigation.

Who Should NOT Lead an Investigation?

There are two categories of personnel who should not lead incident investigations. The first is the person or people directly involved in the incident. This is not usually controversial, although not for the reason usually cited, which is a lack of objectivity. It is because the person or people directly involved in the incident are unlikely to be trained in conducting incident investigation. The other is that their interest in their own reputation may interfere with their understanding how to prevent recurrences.

This is not to say that the people directly involved in the incident should not be involved in the investigation. After all, who had a better view of the incident. At the very least, people directly involved in the incident need to be called on as witnesses. Moreover, they may have essential skills to bring to the team.

The second category is far more controversial. In fact, some organizations have policies and  procedures requiring that incident investigations be led by someone from this category: the immediate supervisor of the people directly involved in or injured during the incident.

Why not the immediate supervisor?

Like those directly involved in the incident, immediate supervisors are also unlikely to be trained in conducting incident investigations. And like those directly involved in the incident, their interest in their own reputations may interfere with making useful recommendations in preventing recurrences. After all, recommendations will typically include better training, better supervision and workplace rigor, and changes to work conditions. Typically, who has responsibility for recognizing and addressing inadequate training, supervision, workplace rigor, and work conditions? The immediate supervisor.

While an incident investigation should diligently avoid assigning blame, every person is aware of Voltaire’s dictum:  “Every man is guilty of all the good he did not do.”

The Primary Objective

No safety investigation can undo an incident that has already happened. A good investigation, however, can keep similar incidents from happening again. Anything that gets in the way of that is not in the interest of a safety investigation.

If existing policies and procedures require that incident investigations be led by people with other interests, those policies and procedures need to be changed. Every incident investigation needs to be led by someone whose primary interest is the single objective of determining how best to prevent a recurrence of the incident.