Chapter 11Understanding What Went Wrong
When the consequences of a problem are big, a formal investigation is launched. Fortunately, those events are relatively rare, leaving looking into the everyday, ordinary looking problems—often with little to no consequence—to the discretion of a supervisor. But often the only real difference between a major disaster and a non‐event is found in its consequences. Problems with little or no consequence can be the best opportunities to learn about what's really going on in your organization and deal with situations before they become big problems.
At the core of every good investigation are answers to the Fundamental Questions: who, what, when, where, how, and why. The answers to all but the last question—why—are found in the facts. The simple approach is to find the facts first, and save the answers to the question why—conclusion, judgment, opinion—until after you've established the facts.
Understanding what went wrong is only half the battle; coming up with a solution that actually solves the problem is every bit as important. A good solution is one that meets two tests: 1) effectiveness, how well the solution fixes the problem; and 2) efficiency, how much time, effort, and resources are required to implement the solution.
Finally, never forget that every investigation meets the definition of a Moment of High Influence.
Preparation Questions
- How often do you get reports of “minor safety problems” that don't reach the threshold of requiring ...