Institute of Work Health and Safety / Reporting

Investigation that looks past the last person

The person nearest the harm is the easiest place to stop and the least useful.

An investigation that concludes somebody made an error is almost always accurate and almost never sufficient. Errors are ordinary. Competent people make them daily, and the great majority of the time nothing follows, because something else in the system absorbs the consequence. The question worth answering is why this particular error was not absorbed.

That question leads somewhere useful. It asks what the person knew at the moment of deciding, which is never what the investigation knows afterwards. It asks what pressures were present, what the alternative would have cost them, whether the correct action was actually available, and whether anybody else in similar conditions would have done the same. If the honest answer to the last is yes, then the finding is about the conditions.

The obstacle is that a finding about conditions implicates decisions made further up and often long ago, and a finding about an individual implicates nobody who will read the report. There is a real pull toward the second, and it is not usually dishonest. It is that the first requires somebody senior to accept a conclusion about their own prior choices.

The practical safeguard is to require that any finding naming an individual is accompanied by an answer to why the system depended on that individual being right. Sometimes it legitimately did. Often the question exposes a single point of failure nobody had noticed.

The final defence is procedural and it costs nothing. Any investigation should record what information was available to the person at the moment of the decision, separately from what is known now. Writing those in two columns makes hindsight visible, and it changes the character of the conclusion, because a decision that looks obviously wrong from the end of the story frequently looks reasonable from inside it. That is not an excuse for the outcome; it is the only way to find out what would actually have prevented it.