When we are typically good at event investigation, we can identify where the system failed – one of the components didn’t work, the redundancy system didn’t kick in, or the alarm didn’t go off. And we are pretty good at identifying when someone breaks a rule. Do we really understand why though? Do we pause long enough to peel back a few more layers and start identifying causes – did they break the rule in error, or did they break the rule thinking it was a good thing to do? Were they told to break the rule? Were they often told to break the rule? Is everyone else breaking the rule?
We teach a very powerful skill in causal analysis that says spend enough time identifying causes; if we made a mistake, why did we make a mistake? Why didn’t the system catch it? Why didn’t someone else in the system catch it? But if we made some choices, and may or may not have broken a rule, what were the incentives for it, and why did that seem like a good choice?
Spend enough time working out why people made the choices and you’re going to find some powerful information for why this person did it, and possibly what everyone else is doing. It can also help you find a reliable way you can get better outcomes to prevent this from happening again, and assure the outcomes for those you serve by heightening the awareness of others and hopefully preventing others from making those same choices.