Have you ever been involved in an incident investigation that was really just a checklist of organisational processes? Have there been times when you might have missed something because you became too focused on one aspect and weren’t open to exploring?
I’ve been in these situations. I’ve written reports that were focused on checking off on corporate procedures rather than on understanding what really went on. I’ve prepared reports that were ‘protected’ by legal professional privilege so that what we learnt could not be shared with others. I’ve written reports where I know that there were a range of other factors at play, but I had neither the time nor resources to explore them, so I ‘parked them’ for later (they are still parked!). Is this normal in risk and safety, or is this just my experience?
If this is our approach, what chance do we really have of learning anything?
What are the by-products that come from an approach that advocates ‘we need to make sure this can never happen again’?
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