The Weekly Reflektion 29/2024

In organisations where the employees are worried that being honest may expose them to consequences that may affect their careers, the causes behind an incident may be difficult to identify.

How do you handle lack of openess and honesty during investigations?

During my career in the oil and gas industry, I have led many investigations into incidents which either had or could have had serious consequences. In Norway we are very lucky that the work force is almost always honest in recalling the details of any incident, as there is a culture of understanding that people make mistakes and not firing people who do. Other people have been brought up in cultures where making a mistake will have consequences, even career-ending, which leads to people trying to avoid blame, possibly trying to blame others by either omitting information, or by giving false information. This gives the investigation team a challenge in getting to the actual causes of an incident, therefore causing difficulties in identifying the actions that should be taken to avoid repetition. 

One investigation I led involved people who were obviously worried about the consequences of being honest regarding their roles in the chain of events leading up to the incident. The answers varied from ‘I don’t know’ to ‘I don’t remember’ making clear conclusions difficult. This situation is not a showstopper and can bring value in spite of lack of clarity. Several realistic chains of events were constructed and failed or missing barriers identified for each chain. An evaluation of the status of these failed or missing barriers for each constructed chain of events was carried out, and actions identified to strengthen or establish them. Some of these barriers probably did not fail, or were not missing in this particular incident, but may need establishing and strengthening just the same. The lack of clarity in the chain of events gives an opportunity to widen the coverage of your operational and organizational barriers, still giving value to the organization.

This is a variation on the ‘premortem’ process that Reflekt has discussed in previous Reflektions. As opposed to a ‘postmortem’, where you start with the conclusion, the premortem constructs a chain of events that could lead to a major accident, that has not occurred, and that you are trying to prevent. The barriers in place to stop the constructed chain of event can then be analysed to assess your vulnerability.

Learning opportunities should be grasped with both hands by an organization, even though some involved people may be motivated to hide the truth. Do you make the most of your learning opportunities?