Tactise Blog
How to Find Out the Whole Truth
The more information a company receives about the causes of unscheduled situations, the easier it is to prevent them in the future. Dmitry Kozlov, founder and CEO of Tactise Group and author of the book 'The Tao of Industrial Safety', shared his expertise on incident investigation.
About Tactise Group
Tactise Group is one of the largest companies in the field of industrial safety and efficiency. It offers innovative production management solutions for Russian and global industrial companies, based on a risk-oriented approach.
Is there a single standard for incident investigation?
Standards vary by country. The state regulates investigation deadlines and the forms to be completed. But companies, especially global ones, often expand on the forms and standards for conducting investigations. The most common practice is to investigate incidents based on the actual damage to employee health, equipment, the environment, or the company's reputation. However, in my opinion, it is more reasonable to determine the depth of the investigation based not on the actual damage, but on its potential.
For example, a person fell from a five-meter ladder but got up and walked away. Or even fell and injured a toe but can still walk. The actual consequences in these incidents are minor. However, the potential consequences could have been much more dire—the person still fell from a five-meter height. This can be calculated using a risk assessment matrix and other tools.
If the principle is that the greater the potential of the incident, the higher the level of management and experts involved, this improves the quality and effectiveness of investigations (they essentially go "up" and "outward").
For instance, an incident with high potential occurred involving lifting mechanisms: something was being lifted, and part of the building was damaged or a person was hit. The investigation would involve the production director, crane mechanics, occupational health and safety (OHS) specialists, and those responsible for employee training. The full composition of the team and the diversity of opinions should be determined by the incident's potential.
Regarding deadlines, they are set by legislation. But the more complex the incident, the longer the investigation takes. An investigation can last up to 15 days. However, typically, if an incident is serious or has high potential, special deadlines are provided for such cases.
For example, a person fell from a five-meter ladder but got up and walked away. Or even fell and injured a toe but can still walk. The actual consequences in these incidents are minor. However, the potential consequences could have been much more dire—the person still fell from a five-meter height. This can be calculated using a risk assessment matrix and other tools.
If the principle is that the greater the potential of the incident, the higher the level of management and experts involved, this improves the quality and effectiveness of investigations (they essentially go "up" and "outward").
For instance, an incident with high potential occurred involving lifting mechanisms: something was being lifted, and part of the building was damaged or a person was hit. The investigation would involve the production director, crane mechanics, occupational health and safety (OHS) specialists, and those responsible for employee training. The full composition of the team and the diversity of opinions should be determined by the incident's potential.
Regarding deadlines, they are set by legislation. But the more complex the incident, the longer the investigation takes. An investigation can last up to 15 days. However, typically, if an incident is serious or has high potential, special deadlines are provided for such cases.
— What determines the quality of an investigation?
The main thing in a quality investigation is to interview as many people as possible. They will provide 90% of the information. It is important to collect facts, photos, and videos, but the people who were involved in the processes are equally important—the most crucial information is stored in their heads. Do you want to get the real picture? Then you need the truth. Who knows the truth? Only the people who were involved in that incident, those who witnessed it, and those who work in similar positions.
There are methods that act through a "mechanism of investigators"—uncovering details through repression and confrontations. But within a company, such mechanisms usually do not work. Finding the truth while simultaneously demotivating the entire team, including managers, is a poor prospect. The investigator's job is to identify the culprit. But this focus can distract the company from the main goal—to discover and eliminate the real causes of incidents. The goal is not to find who caused the crane breakdown, but why it happened, and what organizational and technical reasons existed.
There are methods that act through a "mechanism of investigators"—uncovering details through repression and confrontations. But within a company, such mechanisms usually do not work. Finding the truth while simultaneously demotivating the entire team, including managers, is a poor prospect. The investigator's job is to identify the culprit. But this focus can distract the company from the main goal—to discover and eliminate the real causes of incidents. The goal is not to find who caused the crane breakdown, but why it happened, and what organizational and technical reasons existed.
It’s not as important to find the one who swung the crane to the side—it’s important to understand why they did it, and to reconstruct the chain of events.
For example, a crane operator decided to move a slab near the roof. You could say he is to blame. But you can search further—and find a deeper cause: the crane couldn't lift the load because of thick oil or a contaminated gearbox, meaning the crane operator simply didn't have the option to do otherwise. Does that mean the mechanics are to blame? And why didn't the mechanics change the oil on time? Perhaps the mechanics did change the oil on time, but they used the wrong type because the standard oil was unavailable due to sanctions. Then, perhaps, the procurement specialists are to blame? But why didn't we stop the operation of that crane since the standard oil wasn't used?
And here’s what is revealed: if we had stopped it, we wouldn't have finished the work on time. We wouldn't have launched the new production line, for which crews were already hired. If we disbanded the crews, the company would incur losses incompatible with its existence—it would simply have to shut down. This chain of events led to the decision to move the slab at an unsafe height.
But even in difficult situations, additional protective measures can always be taken. Unfortunately, many companies don't strive to know the truth and find the first person to blame without constructing the entire cause-and-effect relationship.
And here’s what is revealed: if we had stopped it, we wouldn't have finished the work on time. We wouldn't have launched the new production line, for which crews were already hired. If we disbanded the crews, the company would incur losses incompatible with its existence—it would simply have to shut down. This chain of events led to the decision to move the slab at an unsafe height.
But even in difficult situations, additional protective measures can always be taken. Unfortunately, many companies don't strive to know the truth and find the first person to blame without constructing the entire cause-and-effect relationship.
Cause and Effect Diagram
Since people always know the truth, it is important for those conducting the internal investigation to be able to build trust within the team and explain to all participants that finding the causes of the incident is the main objective, and resolving it will prevent the recurrence of the incident in the future. It is also important to guarantee all involved in the investigation process that there will be no repercussions for the errors they disclose. The mindset must change from "if I tell the truth, I will be fired and penalized" to "I can speak openly and honestly."
— Who can we learn from in incident investigation?
I would first mention aviation companies, which particularly need very high reliability, as well as companies in the nuclear and oil and gas industries, where various methodologies are applied: Tripod, Top-Set, Root Cause Analysis, and the "Five Whys." Many international companies have been constantly engaged in finding the causes of incidents for over 20–30 years.
Case Study from Dmitry Kozlov's Practice
At a coal mine, we once noticed a prerequisite for a serious incident—a special safety guard for ventilation was not installed in case of blasting operations. We asked the workers why the guard wasn't in place. It turned out that each protective box weighed about 30 kilograms, making it very difficult to lift. After this, the box was replaced with a lighter one that was easier to install. It became easier for people to ensure safety requirements, and the problem was eliminated.
At a coal mine, we once noticed a prerequisite for a serious incident—a special safety guard for ventilation was not installed in case of blasting operations. We asked the workers why the guard wasn't in place. It turned out that each protective box weighed about 30 kilograms, making it very difficult to lift. After this, the box was replaced with a lighter one that was easier to install. It became easier for people to ensure safety requirements, and the problem was eliminated.