When investigating incidents, safety professionals must consider the amount of time available and organizational limits. If the investigation process recognizes deficiencies in management systems, the place at which investigators stop may be at the realistic organizational boundary. Consider the internally prepared report on the Deepwater Horizon explosion (BP, 2010). The executive summary contains the following terms: "the causal chain of events"; "possible contributing factors"; and "caused this accident." Here's an excerpt from the executive summary. The team did not identify any single action or inaction that caused this accident. Rather, a complex and interlinked series of mechanical failures, human judgments, engineering design, operational implementation and team interfaces came together to allow the initiation and escalation of the accident. Multiple companies, work teams and circumstances were involved over time. (p. 11) The second sentence in the excerpt contains five subjects indicating management system deficiencies. If an investigation system requires in-depth inquiry to include identification of causal factors such as mechanical failures, human judgment, engineering design, operational implementation and team interfaces, the system stops at a high management level and causal/contributing factors are found, not created. Some may suggest that investigations should continue further to determine how each management system deficiency came to be. While that would be nice to do, investigators could say that getting as far into management system deficiencies as the BP team did may be as far as internally employed investigators can practicably go due to cultural and organizational limitations. The BP report would receive a superior rating in relation to the quality of causal factors identified compared to the more than 1,800 investigation reports the author has reviewed. If an investigation process determines how and why an incident occurs and identifies the deficiencies in management systems, the contributing factors (the root-causal factors if one elects to so name them) are identified. Improving incident investigation quality is much more important than the terminology an organiza- tion adopts. The ultimate goal is to achieve superior investigations. If an incident's why and how are cited in investigation reports, the investigators will have determined the root-causal factors and arrived at an appropriate stopping point. If the system in place reveals multiple causal/contributing factors and it works, what the factors are called is of less significance. Safety professionals cannot let semantics get in the way of accomplishment. If what an organization has in place is effective, it is best to stick with it. Although incident investigations may not achieve absolute certainty in determining root-causal factors, having recognized that uncertainty, safety professionals can give advice that can be practicably applied with respect to root-causal factors and the management system improvements required.
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