Conventional logic suggests that we fix the gaps that we find in investigations. But is this the case?
Is the investigation process more a game of sociopolitical whack-a-mole, finding and fixing the things that are easily solved or understandable, or tolerable to the organisation?
Ref: Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2010). What you find is not always what you fix—How other aspects than causes of accidents decide recommendations for remedial actions. Accident Analysis & Prevention, 42(6), 2132-2139.
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Transcription:
We investigate, we analyze, and we identify contributing factors.
Then, we recommend fixes.
Simple, right?
Or is it?
Our investigation searches for truth
or more a game of socially-negotiated whack-a-mole.
Influenced by competing socio-political influences.
Less about fixing issues
and more about systemic pressures and biases
shaping what factors we construct, find, or dare to find.
Let’s explore how aspects other than causes
influence what we find and fix.
Good day, everyone. I’m Ben Hutchinson, and this is SafeHazz,
a podcast dedicated to the thrifty analysis of safety,
risk, and performance research.
Jump onto safetyinsights.org for more research.
Today’s study is one of my favourites, titled
What You Find Is Not Always What You Fix
How Other Aspects Than Causes of Accidents
Decide Recommendations for Remedial Actions
by Lundberg, Roland Hagen, and Holnagel.
Published an Accident Analysis and Prevention in 2010.
So for methods, they interviewed 22 accident investigators
to understand the hidden constraints
that pull investigations away from the ideal assumption.
What you find is what you fix.
In essence, how does the same organisational context
that contributes to accidents
also constrain the investigation process
shaping the causal factors that are identified for remediation?
So what do they find?
While investigators believe that they followed
the What You Find Is What You Fix ideal,
the data showed that analysis and the design of actions
are heavily influenced by practical constraints.
As the authors put it,
“This results in the reality that
what you find is not always what you fix.”
There’s too much to cover in this paper,
but here’s a few of the key findings.
What you fix depends on what you can understand.
This relates to the investigator’s experience
and their knowledge of the task.
This constrains what they can actually find and fix.
What you fix depends on what you can afford to investigate.
Resources and time are major limitations.
What you fix depends on what you can find.
Investigators struggle to speak
with all of the relevant stakeholders,
especially outside of their own company.
What you fix depends on what you dare to find.
Management isn’t always open to criticism,
which can hinder examining management influences,
echoing findings from major accidents
like the NASA Challenger Shuttle Disaster.
What you are able to fix depends on what you find
or when you stop looking.
Investigations often stop based on arbitrary stop rules,
like ticking off all the facts
or identifying a set number of fixes
or stopping where you run out of time.
They do this rather than a comprehensive understanding
or deep dive.
What you know how to fix is what you fix.
Investigators might gravitate
towards problems with known remedies,
even if more complicated but effective strategies exist.
This can lead to fixing what’s easy,
not necessarily what’s best.
What you fix depends on what is easy to understand
and known to work.
This prioritizes readily available solutions
and established rules,
even if they’re not the most targeted
or suitable for that context.
What you fix depends on what you’re going to fix anyway.
Sometimes investigations simply validate preconceived fixes
or fixes that support their existing worldviews.
So we find and fix things we were going to find
and fix anyway.
What you fix depends on what someone else decides.
Recommendations may be overruled by higher-ups
and those with power,
but also by people who might actually lack direct familiarity
with the issues.
And what you fix depends on the cost-benefit balance.
Despite claims for the contrary,
cost often influence the types of actions taken,
sometimes leading to less expensive temporary fixes.
So there’s a bigger picture.
The authors argue that while thorough investigation methods
are still useful, they’re unlikely to prevent most
of the factors mentioned by these investigators
from leaning investigation away from that ideal
of what you look for is what you fix.
Said differently, these influences are at play
in all investigations regardless of the methods used.
You might think that you’re immune from these issues
or that using method A isn’t susceptible,
but these sorts of factors in some capacity
and configuration likely exist in all investigations.
Interestingly, no investigator blamed
poor investigation methods as a constraint.
Instead, they highlighted these external
and internal pressures.
This suggests that accident investigation
isn’t purely rational nor is the choice of actions.
Perhaps as the authors pragmatically suggest,
it is actually irrational to consider the possibilities
and constraints of a situation when selecting fixes.
Also, it’s not necessarily based on flawed thinking.
Many of these constraints are socio-political,
not cognitive biases.
So what can we make of this?
Besides the obvious of considering investigations
as socially-negotiated activities,
another implication is how we treat the findings.
If we see investigation findings
as simply some areas for improvement, then happy dance.
But if we see them as purveyors of reality,
confirmation that our systems are working
and risk are acceptable,
then I think we really need to reconsider.
Paraphrasing Andrew Hopkins, “Bad news doesn’t travel well.”
So what were some limitations?
Of course, with just 22 investigators,
sample size is always a consideration
when considering how generalizable are the findings.
However, other research does support the investigations
are indeed affected by various socio-political influences.
That’s it on Safe As.
I’m Ben Hutchinson and hope you found this useful.
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