Learning from incidents in times of lockdown.
Pic: The primary working from home tools for a remote incident investigation
“New challenges create demands for new ways of working”
A statement like this is probably chore vocabulary in any community or workplace that has undergone some form of change management.
However, the interesting part here is putting that statement in a specific context. The recent social lockdown has been rather extreme. This has called for a complete re-evaluation of most of the taken for granted approaches on, for example how to engage with a client who has a need to investigate an incident. In April, we (NewView Consulting and Tapora) were confronted with exactly this challenge.
A client in Denmark was confronted with a serious incident at one of their sites. The severity of the injury to one their employees necessitated hospitalization and the potential outcome could easily have become a permanent disability under slightly different circumstances.
Under normal circumstances we usually initiate an immediate mobilization, and travel to the site in an instant. Next, we would execute an opening meeting, complete site visits as well as interviews on site or on related company premises within a day or two. It resembles the format of an agile sprint in project management and a report would be ready for handover, within the next 10 working days.
All of sudden, none of this was an option anymore. The lockdown on a global scale as well as activation of the client´s own crisis management measures have created a number of substantial constraints:
Travel and accommodation were almost impossible to arrange.
Company internal rules did not permit access to site for anyone else than own essential employees.
Access to interviewees was hampered by mandatory employee vacation, ordered by the client.
“In short: we could not travel, even if that were possible, we would not be allowed inside client premises and the people we needed to interview had been sent home on vacation, due to the financial and operational downturn accompanying the lockdown”
In short: we could not travel, and even if that were possible, we were not be allowed inside the client´s premises. In addition, the people we needed to interview were sent home on vacation, due to the financial and operational downturn accompanying the lockdown.
So, it was time to test how much can actually be achieved on digital collaboration platforms.
The incident investigation was initiated with an online opening meeting, consisting of ourselves, the clients HSE manager and the HSE site-managers. Here we laid down a strategy for how to engage in the investigation based on information provided through site management and access to key interviewees.
Fortunately, the incident itself had been thoroughly documented with photographs. Further documentation including more general site information and additional pictures of the overall work site were provided quickly, as the demand arose. The interview phase was constrained by access to interviewees and had to be stretched over a period of two weeks.
Given the constraints the investigation could have dragged out even further but a collaborative atmosphere during the entire process instead led to the possibility for us to call involved parties at home during their vacation or convalescence time. As not all of these had access to company laptops, some of these interviews were held through simple phone calls.
The gathered data was then analysed and organised by us, according to the client´s preferred framework of investigation methods and the proposed results were calibrated in an online workshop together with site HSE management. Regardless of the methods applied, we always put emphasis on learning about why human actions and assessments made sense at the time the incident happened and what the system as a consequence can learn about itself. Further, we always ensure a clear traceability between the generic steps in the process: Data Gathering – Analysis – Conclusions – and Recommendations.
With regards to the development of recommendations we also needed to consider yet another consequence of the current crisis. Namely, the client´s current limitations regarding capital expenditure. The question hence became: “What can we credibly recommend to a client in such a situation?”.
Together with HSE management we decided on a two-tier approach. This meant dividing recommendations into a high-level tier for what optimally should be pursued in the longer term and providing more pragmatic level tier with proposals on how to mitigate the risks to an acceptable level here and now.
This in return may actually have created additional buy-in by operational management. Through this approach they received confirmation that their HSE colleagues are very well attuned to the fact that Production and Safety have to go hand in hand for the creation of business success.
Finally, an evaluation of the investigation is required. While the applicability of this approach may vary with the degree of own experience, knowledge of the client and complexity of the incident our evaluation is the following:
The remote investigation approach turned out to be highly effective and sufficiently thorough. Discussing this topic with the client, there was consensus that we actually succeeded in harvesting the incident for its full learning potential. Looking forward we are confident it can work well for low to medium complexity incidents in conjunction with the use of experienced Investigators in a work environment with a collaborative learning atmosphere in the wake of failure.
When it comes to time spent, the process duration was longer due to the special circumstances. However, while the duration of the investigation became stretched, the incident investigation turned out to be less time consuming compared to what is often necessary in terms of travel, site visits, meetings etc. In Fact, we in total spent no more than 40% of the time in external consulting services compared to, what otherwise would have been necessary.