A risk manager called me about an incident investigation at his organization. Before he had the chance to interview anyone, his colleague and the program’s leadership already settled the matter between them. They decided the whole thing came down to bad judgment by the staff in the field.
His question to me was, What am I supposed to do with that? Where do I go from here?
80% of risks are introduced before anyone steps foot in the field
The idea that “risks are introduced upstream” is widely accepted by now. This risk manager has decades of experience and was converted years ago.
Roughly 80% of risks are introduced before anyone sets foot in the field, in the program design and planning stages. It’s true for third-party providers running outdoor education programs, and it’s true for schools running field trips and travel excursions. I wrote about it a few weeks ago in The 80%. When I share this thesis at conferences and staff training, people generally nod along in agreement.
It makes sense, and it’s fairly intuitive. So why do experienced executives, program directors, and risk managers continually skip past it when it comes to learning from incidents and events in their organization? Does the theory not click? Are we not translating well enough from theory to practice?
The guy on the other end of the line was debating with himself. He was trying to decide whether to let it go and let the rest of the investigation run its course, or intervene and provide some mentorship on accident causation and organizational learning.
Let’s try a different approach,
-I said.
What do you think would happen if, when they present their thesis that the instructors had bad judgment and needed more training, you accepted it instead of pushing on it? What would happen if, instead, you followed it up with:
Ok, great. What should change as a result of this finding?
He thought they’d say how they need more qualified staff, better training, and clearer escalation criteria, or a policy informed by medical and mental health experts for this exact type of situation. And that they’d be right that every one of those factors contributes to good or bad judgment in the field.
Great. Now, put on your coaching hat. Now you can ask them about the evidence they’ve found to support those theories, and whether or not they need to do more investigating
Safety leadership is about finding what helps and hinders judgment.
That’s where the actionable learning is. If the investigation stops at bad judgment and decision-making, the organization doesn’t get anything usable. There’s no actionable learning for the budget holders, the hiring managers, the trainers, the schedulers, the partnership managers, or the risk management committee.
In this case, the need for more qualified staff, better training, escalation criteria, and program policy weren’t findings yet. They were asks. The program leadership team already knows their program is missing essential ingredients. Yet, their own investigation didn’t do them any favors. It didn’t give organizational leaders a voice to why those things matter for safety, reputational, or operational risk.
An investigation that ends on judgment does little to improve a program’s resources or infrastructure. An investigation that ends with evidence will often support the normal asks program leaders have of their colleagues in neighboring support and business departments.
Somewhere in your organization, somebody is asking for something they’ve asked for before.
What does your last investigation have to say about it?
P.S. I’ve previously written about the impact incidents can have on everyone involved, from the field to the office staff, and on the organization itself, in After a student death, your staff are victims too.
Right on. Field staff judgment, like safety itself, is an emerging property. This makes it a lousy contributing factor and a hopeless "root cause" for an incident. Judgment emerges from the structures in place around the upstream risks; how well they function but--more importantly--how well they are integrated. Staff training, for instance, has to be kept aligned with the gap between the minimum qualifications to be hired, and the experience, skills and cultural understanding needed to do the work well. Change either the qualifications to get in the door, as you might to recruit from a broader staff pool, or change the work, as you might when you develop a new program, and the training has to shift to align with a gap that is now a different shape and in a different place. Same with the field support systems; they need to change when any other part of the system changes.