DSS011: The Learning Review - A New Approach to Incident Investigation with Dr. Ivan Pupulidy

In this episode of the Dust Safety Science podcast, we have a return guest: Dr. Ivan Pupulidy. You may remember Ivan from episode six, “A Call to Action on Combustible Dust from the US Chemical Safety Board – With Cheryl Mackenzie and Dr. Ivan Pupulidy,” where we discussed the U.S. Chemical Safety Board and its call to action on combustible dust.

Today, we’ll be talking with Dr. Pupulidy about incident investigation. This discussion includes material from a paper titled The Learning Review: Adding to the accident investigation toolbox, which he co-authored with Crista Vesel of Dynamic Inquiry LLC. This work, submitted as part of the European Safety Reliability and Data Association’s Fifty-Third seminar in November 2017, accomplished the following:

Challenged traditional incident investigation and taking a new approach
Questioned some of the processes involved
Re-examininged the value in the lessons we learn from incident investigation

Ivan was Director of the Office of Innovation and Learning for the U.S. Forest Service for over twenty years. When he lost an increasing number of friends in aviation accidents related to the fighting of wildfires, he had to become part of a solution. He became an aviation safety manager after attending the Air Force safety program, the Navy safety program, and the USC Aviation Safety Certificate program and tried to bring about change in how incidents were investigated.

Linear Thinking: the Traditional Approach to Incident Investigation

Many incident investigation courses follow linear thinking:

We know this happens, so then what happened to cause that, and what happened to cause that?
What human error led to the root cause?

Which begs the question: do incidents actually happen in this kind of linear manner?

Ivan sees it as more of a systems approach between simple, complicated, and complex systems and says that complex systems that are more relevant to large scale forest fires and industrial accidents.

Complex Systems: How They Differ

When Ivan entered the field and saw what was happening with ground fire personnel, he recognized there was something missing in the approach to incident investigation. He realized the approach was fundamentally geared for simple and complicated systems. The incidents represented a complex system, which required an entirely different way of looking at things.

In simple and complicated systems, their cause and effect relationship is very strong. But with complex systems, if something happens there is an infinite variety of outcomes that could result. The same input can have drastically different output depending on the circumstances. So, using a direct cause and effect methodology doesn’t work.

One of the difficulties that results from this kind of cause and effect methodology is that we end up trying to find fault and create what Ivan calls ‘second victims’.

In a classic investigation, we tend to find fault with an employee that’s involved. For some actions which bring about improvements in, say, productivity, they are rewarded. However, when the same action brings an incident, they are castigated for doing the exact same thing that they did the day before. Although they are generally well-intentioned and not doing anything maliciously, they are blamed for the incident.

Ivan’s line of thinking against fault-finding leads us to an important principle: actions and decisions of workers that cause an incident should be viewed as consequences of the overall system rather than causes.

We should then be asking:

Why did a person believe that their course of action was the best one?
How does the setting influence their thinking?
How does the pressure they’re under influence their thinking?
How did all of this contribute to the incident?

Taking the Sense-Making Approach

All of the above questions creates a transition from the traditional investigation approach to more of a sense-making approach. Now, we need to ask ourselves:

Why did it make sense for those workers to do what they did at that time?
Where their choices part of otherwise normal operation?
How can we change those processes to make the facility safer?

Ivan recommends two tools in his learning review:

Complex narrative: In this case, investigators interview people involved in the incident to get multiple perspectives. These are collected to get multiple viewpoints of the incident. Rarely can a single timeline or cause be identified as people tend to remember things in different ways and all perspectives will contain a “piece of the puzzle”.
Network of influences map: This tool examines the influences that affected the workers at the time of the incident. This tool follows the thought that an employee’s decisions are a consequence of the overall system and not causes of the incident.

The complex narrative and the network of influences map provide investigators with an idea of the different conditions at work at the time of the incident. We can then determine if these conditions are typically present and, if they are, correct them.

Although direct relation cannot be established, after the learning review process replaced, and in some instances supplemented, the traditional Serious Accident Investigation Process at the US Forest Services, that department saw a significant reduction in incidents.

The influence of this type of approach can also be seen on recent programs like the U.S. Chemical Safety Board’s Call to Action on Combustible Dust, which we covered in Episode 6 of the podcast and some of the new investigative methodologies have been implemented over the last few years.

Empowering Workers

In industrial environments, most workers would willingly stop work if they knew a fire or explosion would occur. But if they are not 100% sure, they may not want to give up the time and productivity.

This is in contrast to changes seen in the aviation industry. In a paper entitled The Self-Designing High-Reliability Organization: Aircraft Carrier Flight Operations at Sea, Gene Rocklin, Todd LaPorte, and Karlene Roberts observed aircraft carrier operations and noted that even the lowest ranking person on the flight deck could call stop work. If they did, they were not chastised regardless of the outcome.

What we have to realize is that most approaches to incident investigation are taken from the perspective of an investigator who already knows the outcome. The worker doesn’t know whether the outcome is going to be positive or negative until something does or does not happen.

We have to start taking a holistic approach that accepts a worker isn’t the failed component inside the system. Instead, the worker is the person who is trying to make the best decision that they can and sometimes fail.

Conclusion

Ivan’s learning review process introduced a new way of thinking about incident investigation. Now the question is: how can we apply it to combustible dust safety and learn from our own incidents as we move forward?

As 2019 progresses, we will probably see more non-traditional approaches to incident investigation start to take hold, especially in areas like the U.S. Chemical Safety Board’s incident reports. Hopefully, we can learn from fires and explosions as they occur and decrease the number of incidents that result in injuries and/or fatalities.