Engaging Stakeholders in Incident Investigations

I’m a back up member of an organization’s investigation team and last month I had the opportunity to conduct a serious near miss incident investigation, and then a few weeks later presented my findings to a group of stakeholders in the form of a Power Point presentation. The stakeholder group included the workers directly involved in the incident, their supervisors both on site and off site, contractors and senior management for the area.

This organization like all my clients shall remain nameless. They are unique in their approach to investigations, in that they have full time root cause investigators, and they treat investigations as a true learning and improvement opportunity through the involvement of stakeholders in addressing incident causes.

With the exception of using dedicated investigators their initial investigation process is not unlike others. After the scene has been visited, physical evidence gathered, and witnesses interviewed, a report is produced containing only the facts of the matter which include both the physical and human causes of the incident. While the investigator might include some thoughts about corrective actions, their purpose is only to stimulate discussion. The opinions of the investigator are not part of the report. The belief being that when the facts are presented to the stakeholders they will speak for themselves and no other input or commentary is necessary. (This was different for me as I’m usually expected to offer an expert opinion as to cause and levels of responsibility.)

Once the stakeholders have seen the photographs, sketches and facts obtained from both witness and investigator observations, and are satisfied they are accurate; the meeting is turned over to the stakeholders. The presenter’s role now becomes one of simply guiding the discussion as stakeholders review the events and come to conclusions as to causes and corrective actions.

As all the stakeholders are present, finger pointing seldom occurs, but rather an honest examination and discussion of both individual and organization causal factors occurs. The meeting concludes with stakeholders identifying corrective actions and jointly agreeing on completion time lines and the stakeholder responsible for overseeing the completion of the corrective actions.

This exercise took a half day with about one third of the time allocated to the presentation and the balance to the stakeholder discussion. I found it interesting that one of the potential corrective actions I had identified never saw the light of day after the stakeholder discussion. This serves to point out the power of this process in that what I initially felt might be a good fix didn’t fit with where the stakeholders were heading.

No doubt many of you solicit input from similar stakeholder groups during your investigations and incorporate it into your findings and recommendations. The main difference here is that all the stakeholders are present at the same time, and the facts are laid before them. As they are facts, there’s little need to discuss the “what happened” as compared to the “why” and the “how” we are going to fix it.

This brief explanation does not do justice to the process. It’s something that you wouldn’t use for every incident, but rather for high potential incidents or near miss situations. If you are thinking there might be an opportunity to try this in your organization and want some more information give me a call, and I walk you through the process in more detail.

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