Nippin Anand 0:00
Hello. As some of you might know, I wrote this book, are we learning from accidents nearly a year ago now, and in this session, I would like to ask the question, how can we possibly learn from accidents, particularly because I have suggested a way forward. So we will go a little bit into that and and so let’s get started. So here are the four questions that I would like to address in this session. The first one is, what is an accident, and then what is learning? Who needs to learn and how we can possibly learn from accidents? Let’s begin. With what an accident is, and just take a very simple situation. You know, you are setting off from home to office. It’s eight o’clock in the morning, and it’s good weather, as you were expecting, and the car is well maintained, you jump into the car you’re driving. Now you’re halfway somewhere in between the office and home, and another car comes and hits you from behind. So that could be qualified as an accident. It is an accident because you were not expecting this to happen, or in some ways, your expectations are proven wrong. You wrong, and in many ways, if you think about it, anything from a surprise all the way to a near miss, a hazard, an incident, an accident, a customer complaint, a technical defect, sits within this category of what you could loosely call an accident, your expectation has been proven wrong, or the unexpected happens. Now, what is important in those situations is what you learn from that particular unexpected situation, and a lot of learning will depend upon how we respond, how we respond, or rather react in that moment, I use the word react because that’s precisely what happens that we end up pointing fingers at someone or something. It could be a machinery we want to blame, which doesn’t help very much when it comes to learning, and so let’s ask the question, who needs to learn? Because unless we understand that, it’s very little we can do to learn. There are two people who we expect to learn from the accident. Obviously, the first one is the one who is involved in the accident. We don’t want that person to get involved in an accident again, so we obviously want them to learn from it, but we also want the person, or the group of people who are responsible for conducting the investigation to learn from that accident, so that we can learn from them, often in the form of how they analyze, how they process the information, how they report, how they present the accident investigation narrative. Now the key thing to understand is this, that to a degree, both of these people are actually under stress and for different reasons. Let’s look at that. This is the person who is involved in the accident, and this person is stressed because guilt and shame takes over. Why does it have to be me, and how am I going to face my colleagues, my co workers, my supervisor, my boss. So there’s an element of shame, there’s an element of job insecurity that, you know, I might lose my job now. So this person is under immense stress. Perhaps it would be fair to say this. This person is even traumatized as a result of the accident, depending on the severity of the problem and their tolerance levels. The other person who is under stress is the one who is investigating. Often, we don’t see that, but think about it, an accident has happened, something has gone wrong, and now you are under immense pressure, because you have to produce a result. You have to find out what has gone wrong, and you have to write a report all within time pressure, and we know for sure that when people are under stress, they are not themselves, they struggle to make sense of what is happening. And this is a very, very important point to understand, because when people are not themselves. Their perception will not match with reality. They’re giving you something which is so far away and distanced from reality, and we are taking their their their investigation, their information, their data, as the basis for all learning. So although. So the idea is to prevent accidents, we are relying on some very distorted information of reality, which is not very helpful when it comes to learning. So here’s the question for all of us, that when we do not understand how stress works and how the two people who we are relying on are so under pressure, the learning from an accident becomes very questionable, not only prevention and learning, but also their well being becomes very questionable. What is it that we are doing in the name of investigation? Is it being counterproductive to everything that we want to achieve from it? And that happens a lot. So

Nippin Anand 5:45
which brings me to the question of, what exactly is learning? What is learning? So again, we need to ask the same question, who are the people that we are relying upon when it comes to learning, and why is this question important to a degree, if you think about learning, and if you think about the investigators who are responsible for generating learning, nearly all investigators are hired in their field of expertise, for their domain specific knowledge and experience, and you pick up any job at work of an accident investigator. The first and the most important thing is, how many years have you served in order for you to qualify as an investigator? This is a very important point to understand, because we are trying to make sense of the unexpected, which is often a very novel situation. And the paradox, paradox of experience is that one must be very, very aware of the limits of their experience and shouldn’t be afraid of letting go of what they already know when it comes to learning. Now think about it. There are many investigators that I know of, and research has highlighted, who at the start of the investigation would already tell you that they know where this is headed. This is not very helpful for learning what you want or what you expect when it comes to learning, is an element of discovery that I have found something that I was not aware of. This can only happen when investigators come to terms with the limits of their experience. In other words, they become self aware. Equally interesting is to understand the nature of decision making when it comes to people involved in accidents. Now this is not a surprise to people who understand the science of decision making, that nearly 98% of our decisions are made in the unconscious space, meaning we are not aware of how and when and where we made those decisions. So for example, if you’re talking about experts, people who have spent years and years in a profession, they work through their habits, their heuristics, their body language, their gestures, in order to produce results, and that’s how they become efficient. The trouble is that when things go wrong, a lot of times, they are not aware of those habits, and that’s precisely why they are called Habits, because they are operating in the automatic mode. Part of it is our ability to help these people discover the unconscious nature of their decision making, which we call discovery. Are you able to reflect upon the fact that you have made certain decision not being aware of them? That takes a skill in its own it takes a level of sophistication. It takes a level of understanding how to ask questions and how not to ask questions. When we set this equation between discovery and letting go, we create a cycle of unlearning and relearning, both on the part of the investigator, but also on the part of the one being investigated. But here we will focus on people who are responsible for investigating accidents and everyday work. So which brings me to the question of, what are those essential investigation skills that you need in order to maintain or in order to create that cycle of unlearning and relearning, and one of the most important skills as an investigator is to be able to listen. Now this is no ordinary listening. This means being able to listen to the metaphors, to the symbolic language, the ability to step into people’s shoes and try to listen from their perspective. Let’s take a simple example. During an investigation, somebody tells you that this happened just after the coffee break. I went for a coffee break, and I came back and I tried to open this, this valve, and suddenly the liquid slash slashed on my on my face. Uh, of scattered on my face. The investigator, in this instance, should be able to question, what is a coffee break? For example, metaphorically speaking, a coffee break for an investigator could mean that when you’re you’re you are you know, a break in between work where people get together, have a cup of coffee, relax, share some have some conversations, have fun, which helps them to relax and come back to work again. It’s a nice break. And hence the word coffee break. But if you are an investigator who understands that words have hidden meaning, and it’s only the meaning of the word, only can be clarified from the person who’s speaking those words or owns those words, that means you’re more attuned to metaphorical thinking. Now it turns out that when you ask the question of coffee break, this person might tell you a completely different story, that the coffee break is not about relaxing and chatting with your colleagues, it’s actually going back to your private space and checking your emails, or even going on the social media and responding to your friends on Facebook, which reinforces a culture of isolation. Now, whether this has happened or not, is a material my point through this example is that, are you able to listen metaphorically? Are you able to listen symbolically as people are speaking? And that is where an investigator skills counts, because what happens most of the times is when we listen to somebody, we listen to them through the lenses of our own experience, and we are not very good at asking questions. Worse still, what we do is we take their words and in a very, very literal sense, and that’s how we are taught in most investigation programs. We are not taught to think metaphorically, to think symbolically. So this leap that we make between listening and learning can only be bridged if we start to think metaphorically and symbolically and from the point of view of people who are involved in the accident, the other important aspect of a good investigation skills is the ability to balance expectations now an accident happens, and an organization expects an answer in three days or five days or even 24 hours. Now, if I gave you this job to go and investigate, you would say I need to do that at any cost, which means that all that matters is to produce an investigation report in three days, which, to be honest, anyone could do if I gave them a checklist and a process. But where good investigation skills would count is the ability to walk this difficult path between what is expected from your organization and how you can sense the state of this person who’s been traumatized or who’s been under immense stress, and being capable of recognizing that stress and balancing those two expectations. And for that, for example, let’s take the case of are investigations or investigators able to recognize trauma when they are investigating people, because quite often, you’re not investigating machineries, you’re not investigating control rooms. You’re actually investigating people who are under immense pressure, distressed and even traumatized. Studies after studies have indicated that recognizing trauma takes a bit of sophistication. People are functioning normally and suddenly, an accident happens, something unexpected happens, and they are in a trauma. The first thing is shock and denial. This cannot happen to me. Complete fear, numbness, trying to blame everyone and everything around them. They could be angry, they could be depressed. And this is where a good investigation or investigator matters. If you talk to people, they will tell you this one thing that it was not so much the accident, it was the process of going through the investigation that has put them in this traumatic state for a very, very long time. And what they are telling you is that this, that if you cannot recognize trauma, you are doing injustice to your job, you are doing injustice to people who have been caught in that moment, because nothing is worse than being stuck in that stage for a very long time, and that happens more often than we think so, the ability to listen to people and try and understand where they are. Even seeking help if you think that they are traumatized, and reaching out to an expert or a counselor is a skill in its own of course, you are not a counselor. You are not trained as a counselor, but are you able to listen to this person and understand where they are in their trauma? This could be an immense way forward for you to help these people as you are extracting information from them in the hope that you will learn something.

Nippin Anand 15:27
And this is where good investigation skills will count. And if there is nothing else you want to do, I would invite you to read this one book, which is called the Body Keeps the Score. And it is a very, very good book to read for any investigator, because it might help you to deal with people who are in trauma. There are many other books, but this would be a good start. It would give you some solid understanding of how to recognize trauma as people are speaking to you. So to summarize this discussion, how can we learn from accidents, possibly the first thing or the first place, is to start becoming conscious of the metaphorical nature of all speaking, that when people speak, they speak metaphorically. And it’s not important what you are hearing. What is important is what they are saying. And in order to come to some kind of shared understanding, we must be able to understand the symbolic nature or the hidden meaning of words, which we can only know if we understand how to ask open questions, how to listen symbolically, how to listen metaphorically. The second thing is this, once you understand, once you can listen well, and you can listen from the perspective of people involved in the accident, it would help you to build an accurate picture of the reality, something that we do in IQ mapping, where we actually map the words of people as they are speaking, and the famous expression I see what you mean, applies very much in that case, that now that you are saying something, and you’re verbalizing your thoughts and I’m putting them on a whiteboard, I can actually see what you mean. And this is what you call metaphorical mapping, that you map the words of people as they are speaking, which helps you to build an accurate picture of what happened in their world, not from your perspective, but from their perspective. And don’t be afraid to walk away or to say that I cannot help in this situation because the situation is so bad, the person is so much in distress and trauma that you’re not able to help in that situation and you do not have the right skills, and in those moments, it is very, very important to know the limits of your understanding, your expertise and reaching out to somebody who is equipped with the right skills to help this person or else, not only you do not Learn, but you end up traumatizing this person even further. Here are some basic and advanced skills that we cover as part of the accident investigation program based on social psychology of risk. So everything that you see in the red is part of the basic Accident Investigation skills, for example, understanding and identifying investigators biases, listening to people metaphorically, and mapping their words, asking open questions, observing with accuracy the scene of the accident what’s happening, and being aware that our own biases might contaminate or might might distort the picture, understanding what it takes to listen to trade offs and conflicts, understanding how cognitive biases work, understanding how heuristics work and how to ask questions to get access to those mental shortcuts that people take each day, every day, we then go into the green space, which is part of the advanced Accident Investigation skills. This is where we cover things like visual and spatial literacy, wicked problems, cultural intelligence and so on. So these are all part of accident investigation program. And what’s powerful in this picture is the symbol of a donut, which is completely hollow in the in the middle. So the metaphor of the donut reminds us that a lot of what is not taught in the accident investigation course sits in that hollow space. And we need to train people in this space if the aim is to learn from accidents or even perhaps from everyday work. Right? If you wanted to learn more, I will be conducting an interactive sections, interactive session for an hour, and you’re very welcome to join us for this session. It takes about an hour, and we will open up for questions, and I will also help you to think metaphorical. How to listen metaphorically, because that is something which is foundational to all learning in accident investigations, and something that we don’t think about, we don’t talk about an accident investigation. Programs. If you want to learn more, you can visit our website:  novellus.solutions/events and where you will stay, you will see all the programs that we are scheduling, both online and in person, and you’re very welcome to register for these programs if you are interested to learn more about accident investigations, any questions you can send us an email at support@novellus.solutions. So I hope this was helpful to you, and I look forward to seeing you at one of our taster sessions. Thank you for listening. You.