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Leadership Perspectives Blog

Are Your Incident Investigations Pacifiers or Change Agents?

Boom! You get the call. Yes, that call. An incident occurred where a worker sustained a serious injury. It turns out he is a contractor working on one of your projects. The call comes in Tuesday around noon, just before you are about to head out for a quiet lunch, or so you thought.

The process kicks in. Yes, that process. The one where the contractor is told they are responsible for conducting an incident investigation and reporting back their findings. The one where production demands another resource to complete work the injured employee now cannot. The one that strictly uses behavior-based approaches to arrive at “root causes.” You know, the one where if it had been a company employee, more company resources would be devoted to driving toward true prevention processes and outcomes.

The contractor replaces the injured employee with another trained one and your project continues slightly behind schedule but with a promise of an on-time delivery. The contractor completes its investigation and concludes that the injured employee violated their confined space policy by entering a regulated space without a permit. This action resulted in the subject employee losing consciousness due to a low oxygen level. The confined space is well marked as permit-required and the employee is qualified to work within these spaces. The contractor is also authorized to work in this space.

You are informed that the employee will be disciplined and that he will receive remedial training on confined space entry and company policy. If you insist, the employee will be removed from your site. That is it. Another case of another employee exhibiting unsafe behavior. Another case of contractor employee discipline to send a strong message to the rest of the organization that safety rules shall not be violated. Everyone returns back to normal operations and the talk around the office water cooler, well, cools.

Unfortunately, this scenario happens every day and every day there is an opportunity missed to convert your incident investigations from pacifying processes to process changing machines.

Treating contractors at your worksite as if they are someone else’s responsibility is a formula for disaster. The fact is that most of the time, chance is the reason your employee did not get hurt instead of the contractor. An inch here, a fraction of a second there or a failed decision is the only difference between who gets hurt, who goes home at the end of the day and who does not. It is, however, all the same. It is your worksite.

Behavior safety does play an important role in positive workplace behavior modification. That is proven. The issue comes in when behavior safety is used as the only means to derive comprehensive preventive solutions. This approach is one dimensional because it primarily requires behavior modification as the end all for determining root causes. If you stop here, your incident investigation process is merely pacifying an immediate need for answers without ruffling too many feathers and missing on the opportunity to implement an impactful long-term solution.

So where is the missing link? How do you convert your incident investigation process into a change agent tool? For that answer, establish one mindset and ask two questions at the end of every investigation. First, establish a corporate mindset that all outcomes are the result of processes, some more desirable than others. Then, ask your organization this first question: What operational process changes where identified and implemented to prevent this incident from recurring?

Boom! The answer you receive will determine if your team is a change agent or a pacifier of event outcomes. Understanding that you too are part of the process and with their proposed corrective action in hand, answer this second question: What will be your next move as their leader? Your response to the second question will set the stage for your team in the first one.

Dare to think differently.

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