๐๐ผ๐๐น๐ฑ ๐ถ๐ ๐ฏ๐ฒ ๐๐ต๐ฎ๐ ๐ฅ๐ผ๐ผ๐ ๐๐ฎ๐๐๐ฒ ๐๐ป๐ฎ๐น๐๐๐ถ๐ (๐ฎ๐ป๐ฑ ๐ฑ ๐ช๐ต๐โ๐) ๐ฎ๐ฟ๐ฒ ๐ฑ๐ฒ๐๐ถ๐ด๐ป๐ฒ๐ฑ ๐๐ผ ๐ฐ๐ฟ๐ฒ๐ฎ๐๐ฒ ๐๐ถ๐บ๐ฝ๐น๐ถ๐๐๐ถ๐ฐ ๐๐๐ผ๐ฟ๐ถ๐ฒ๐ ๐ผ๐ณ โ๐ต๐๐บ๐ฎ๐ป ๐ฒ๐ฟ๐ฟ๐ผ๐ฟโ?
Here’s a mock interview between a seasoned investigator and a seafarer about an enclosed space entry incident.
๐๐ฉ๐บ ๐ฅ๐ช๐ฅ ๐บ๐ฐ๐ถ ๐ฏ๐ฐ๐ต ๐ง๐ฐ๐ญ๐ญ๐ฐ๐ธ ๐ต๐ฉ๐ฆ ๐ฆ๐ฏ๐ค๐ญ๐ฐ๐ด๐ฆ๐ฅ ๐ด๐ฑ๐ข๐ค๐ฆ ๐ฆ๐ฏ๐ต๐ณ๐บ ๐ค๐ฉ๐ฆ๐ค๐ฌ๐ด?
Because I did not have sufficient time to go through the checklist.
๐๐ฉ๐บ ๐ฅ๐ช๐ฅ ๐บ๐ฐ๐ถ ๐ฏ๐ฐ๐ต ๐ฉ๐ข๐ท๐ฆ ๐ด๐ถ๐ง๐ง๐ช๐ค๐ช๐ฆ๐ฏ๐ต ๐ต๐ช๐ฎ๐ฆ?
Because we were in port, and we had a lot of other things to attend to.
๐๐ฌ๐ข๐บ, ๐ฃ๐ถ๐ต ๐ธ๐ฉ๐บ ๐ธ๐ฆ๐ณ๐ฆ ๐บ๐ฐ๐ถ ๐ข๐ต๐ต๐ฆ๐ฏ๐ฅ๐ช๐ฏ๐จ ๐ต๐ฐ ๐ฐ๐ต๐ฉ๐ฆ๐ณ ๐ต๐ฉ๐ช๐ฏ๐จ๐ด ๐ธ๐ฉ๐ฆ๐ฏ ๐บ๐ฐ๐ถ ๐ข๐ญ๐ณ๐ฆ๐ข๐ฅ๐บ ๐ฉ๐ข๐ฅ ๐ข ๐ต๐ข๐ด๐ฌ ๐ช๐ฏ ๐ฉ๐ข๐ฏ๐ฅ?
I donโt know, but it seems like Iโm in trouble now.
And then both had a good laugh.
๐ง๐ต๐ฒ๐ฟ๐ฒโ๐ ๐บ๐๐ฐ๐ต ๐๐ผ ๐ฟ๐ฒ๐ณ๐น๐ฒ๐ฐ๐ ๐๐ฝ๐ผ๐ป ๐ถ๐ป ๐๐ต๐ถ๐ ๐น๐ถ๐๐๐น๐ฒ ๐ฒ๐ ๐ฐ๐ต๐ฎ๐ป๐ด๐ฒ:
โข The investigator begins with the assumption that there has been a breach of procedure.
โข The response to the first question becomes the basis of inquiry for the next one, and so on. i.e. linear, deductive reasoning becomes the line of inquiry.
โข There is an assumption in this line of inquiry that a decision made in a moment of uncertainty was made in conscious awareness.
โข The onus is on the interviewee to justify his actions.
โข The decision where to end the investigation always rests with the investigator.
And that is how accident investigations turns into simplistic stories of โhuman errorโ.
๐ฆ๐ผ ๐๐ต๐ ๐ต๐ฎ๐ ๐ฅ๐๐ ๐ฝ๐ฟ๐ฒ๐๐ฎ๐ถ๐น๐ฒ๐ฑ ๐ผ๐๐ฒ๐ฟ ๐๐ต๐ฒ ๐๐ฒ๐ฎ๐ฟ๐:
โข RCA is time and resource efficient; it is a match made in heaven for industries, organisations and people who crave for quick fixes and simple solutions.
โข RCA recognises that when things go wrong, humans cannot hold doubt for too long; they want a cause. Any cause is better than none.
โข RCA offers an existential solution (i.e. do this and you will be saved) to problems that are complicated, wicked and unsolvable.
โข RCA gives the organisation a legitimate basis to reveal just enough information without disrupting the status quo.
โข RCA is a cleansing agent and a business friendly tool. It will purge impurities and ensure business as usual post accident.
๐ช๐ต๐ฒ๐ฟ๐ฒ ๐ฅ๐๐ ๐ฏ๐ฒ๐ฐ๐ผ๐บ๐ฒ๐ ๐ฝ๐ฟ๐ผ๐ฏ๐น๐ฒ๐บ๐ฎ๐๐ถ๐ฐ:
1. RCA gives disproportionate powers to the investigators and auditors.
2. RCA seeks rational explanation to non-rational decisions made in a moment of uncertainty.
3. RCA create a delusion of certainty and control where there is none.
4. RCA claims to bring objective truth from subjective persons. (?)
5. RCA is silent on sensemaking and meaning making (foundational to understanding cultural problems in organisations).
If you want to learn about an ethical approach to investigating accidents, please join our LinkedIn event: โ https://lnkd.in/eSn_wtg8
