Why Investigations Should Play a More Significant Role in Safety Management

In this episode, Mary Conquest speaks with Mark Alston, a risk management and safety expert who is the founder of Investigations Differently consultancy.

Mark helps HSE professionals understand why safety investigations can be too narrowly focused and only result in blame rather than benefits.

Fortunately, he shares helpful advice on how you can implement better investigations in your workplace. Mark encourages EHS professionals to move away from a top-down approach and instead harness co-workers as part of the solution to deliver systemic risk reduction.

He argues that safety investigations are great opportunities to enable organizations to learn critical information from their people about how work is actually completed. Furthermore, Marks shows you how this can be used positively to improve overall safety performance.

♪ [music] ♪ - [Mary] My name is Mary Conquest. I'm your host for "Safety Labs by Slice," the podcast where we explore the human side of safety to support safety professionals. We move past regulations and reportables to talk about the core skills of safety leadership, empathy, influence, trust, rapport.

In other words, the soft skills that help you do the hard stuff. ♪ [music] ♪ Hi there, welcome to "Safety Labs by Slice." Investigations are a crucial part of a safety program. Traditionally, they help us answer the question, what went wrong, so we can prevent future incidents. Our guest today specializes in safety investigations and argues that investigations should play a much larger role in our organizations.

We'll discuss different kinds of investigations, how they can influence outcomes for an organization, what investigation maturity looks like, and, of course, what you, dear listener, can do to implement better investigations in your workplace. Mark Alston is our guest today. Mark is the executive director of Investigations Differently, consultancy that helps organizations to harness people as part of the solution.

It also delivers systemic risk reduction for its clients. Mark's extensive experience facilitating organizational learning started with a role as federal agent in the Australian Federal Police. He has more than 20 years in the field, working for organizations such as the Royal Australian Air Force, BHP, Serco, Urban Utilities, and Powerlink.

He specializes in investigations and risk management for mining, construction, and other high-risk industries. Mr. Austin also provides new view workplace investigations training and helps organizations understand their normal work. And if that sounds like an odd term, we'll return to it later. So stay tuned.

Mark joins us from Queensland, Australia. Welcome.

- [Mark] Welcome. Thank you very much. Thanks for having me. I really appreciate being here.

- Yeah, I'm excited to talk about this. And I wanted to start with the language...I say the language around investigations, but it's really the term investigations. I think there is some emotional baggage that comes with that term. Why would you say that?

- Couldn't agree with you more. I think there's a couple of things. I think the emotional baggage is predominantly around the fact that traditional investigations have a lot of blame, they focus on the worker. So the worker failed to follow a procedure, the worker made an error, the worker committed a violation, you know, the worker didn't do something.

And that blame in the investigation result in outcomes such as the worker will be disciplined, the worker will be retrained. The worker will stand up in front of their workmates and admit their error. And say they've been a very naughty person and they would do it all differently if they only thought about it.

And that means people are afraid of reporting incidents because they lead to this investigation. So I think that's a large part of it. And the other part is just the term investigation, we use this investigation. And basically, in safety, we've taken it probably from our regulators across the world, who have taken it from policing and the judicial system. And we're anything but a judicial system in workplace investigations.

There's no judge, no impartial judge, for example, it's the manager who owns the work normally is the last say in an investigation. There's no jury of our peers that, you know, make a decision on guilt or innocence, we don't have that. The people involved don't have the right to a lawyer of some description, or an attorney, or whatever we call them wherever we are.

And there's no right of appeal. So we're actually doing things in this judicial way when it's not a judicial process. And that's part of it. And it's not just the term investigations wrapped up in that, we use terms like witness statement, we use terms like collecting evidence, all these judicial terms, and people don't like getting in trouble.

So, you know, there's no wonder that...you know, Sentis did a survey not long ago, and a third of workers in this survey were aware in the last 12 months of an incident or injury that went unreported. They then took that and asked them the next question, "Why didn't you report it?"

Thirty-five percent or 36%, fear of reporting, you know, and that says it all. So there's a third of incidents that aren't even getting reported through to management. So that's a scary number.

- How would you define...so that's sort of a context of where it came from. When we look at how investigations have been run traditionally, how would you define that, and why do you think that it's not as effective as it could be?

- So traditionally, if we look at most organization system or procedural process around investigations, the objective of an investigation is to come up with actions that will prevent reoccurrence of that same incident. And I'd ask the audience, how well is that working for you, you know? Have a look at all your incidents of the past, and look at your repeat incidents.

And that's been the traditional view of investigations. The problem with that is that to prevent reoccurrence of an incident, you'd have to eliminate the risk of the incident happening again. So to guarantee we don't repeat an incident, you'd have to eliminate the risk. Now, elimination is one of the hardest controls to apply in risk management or investigations, it's just almost impossible.

We can do it, but it's very, very rare. So by driving this in this fashion, what we've done is we've put this fairly unattainable goal on our investigations, which drives us then to focus purely on that event. And what we end up with is a very linear view of what's going on.

The issue happened, the event happened, and then it's why did this happen? Why did this happen? Why did this happen? Why did this happen? And then for some reason, we decide, oh, we need to then define all these issues as either contributing factors, causal factors, or root causes. So the problem with that is failure is almost never linear.

You know, work is incredibly complex and comes from a whole variety of...emerges from the system of work. So it can't be linear, but we focus on this. And then owners of investigations, or risk owners, or managers, then are very definitive about the scope. And they set this very narrow scope, which the investigator is not allowed to travel outside of, and then we don't get to the systemic risk that exists in the business.

And that's where we're at now. That's where we are with most investigations now, we're only identifying some superficial organizational factors, or it's the worker, so we've got to fix the worker. And that's sort of where we are.

- Yeah, as you're speaking, I'm thinking, you know, in order to eliminate the risk, you would have to be able to foresee every possible thing that could go wrong in every possible complex. And you're right, it's not linear, you know, it's always this really weird domino that no one foresaw.

So it would almost have to happen in order for you to prevent it from happening again.

- Exactly. A good example, say, is working at heights or fall from heights. To eliminate a working at heights or fall from heights event in your business and never have it happen again, never have a repeat incident of a working from heights event again in your business, you would literally have to eliminate working at heights from your business.

Now, that's pretty hard in construction, that's pretty hard in maintenance. That's pretty hard in a lot of industries. How would you eliminate working from heights in the construction industry? You couldn't do it.

- So talk to me a little bit more about the difference between event investigations and systemic investigations?

- So when we're looking at...the way we like to term it is the traditional way is this incident investigation, what we look to do is elevate learning. So the difference is, rather than investigate just the event or the incident, what we're doing is we're going to learn about the work, we're going to investigate the task, what's actually happening.

And that's the difference. So rather than...so say we had someone fall from height, we typically would just investigate that. You know, what time they turned up to work, the pre-start meeting, you know, they got their gear on and they went up, and they were working at height, they fell, and they got treated at hospital.

That would be our timeline, that's our event. Or we'd investigate. What we would do is investigate the whole way work at height is done within that organization. You know, we start off with the team and then that site, day shift, nightshift, and we look at the whole process of work at height and how it's impacted. And so we learn about the work, and that's where the systemic issues lie because we're looking for the constraints, and the trade-offs, and the goal conflicts that happen all around that work.

- Yeah, there's often unseen pressures that, you know, one person has said, "Work safely," and the other one has said, "Yes, but faster."

- That's right.

- For example. So this is where we're talking about just that work and how...and so we're just investigating how work happens every day. Because to be quite frank, in industries, particularly in the Western world, we don't have a lot of incidents, you know, particularly, you know, in first-world, second-world countries, we don't actually have a lot of incidents.

So we might have one a month. Now, if we're only looking at how that job was done one time out of a year's worth of work, that's what we're going to get. So we need to understand how it's done 365 days a year, and nights a year if it's on nightshift as well, to really get a understanding or discover an understanding about what's actually happening.

- So when you talk about...and I said we would come back to this. But when you talk about work as normal, is that what you're talking about?

- Yeah, so that's what we call work as normal. And it's based on Professor Todd Conklin's work. And it's that work as imagined, which is our procedures, and our policies, and training. You know, it's looking at what happened on the day when someone may have got hurt. But the crucial bit is that work as normal.

And that's how it happens all the time. That's how it happens on a good day, a bad day, an exceptional day. That's how it happens all the time. So what we're talking about there is what's going on in the workplace that creates sense to the people who do the work, to how they do the work.

So we know for a fact...well, it's not a fact. But we know that it's very hard for a business to have all their work instructions or work procedures 100% complete and 100% correct. In fact, anecdotally, it's around 60% and 70%. Some businesses are quite high, a bit high, some are much lower.

So what are workers doing with the other 40%, 50%? They're adapting, they're making it out, you know, and that's not based out of...that's just not out of nothing. That behavior about what they decide to do on how to complete a task is driven by the conditions that they're working and the systems they're provided by their organization.

And that's how they make those decisions. I'll give you an example. If you ask a team of workers to dig a hole and you give them a digger, or an excavator, or a backhoe, they'll use that machine to dig the hole. You give them some shovels and no backhoe, they'll use shovels because that's what they've got, that's what's been provided.

- And it occurs to me, you know, it would be so easy if you weren't really thinking about it to develop a procedure that makes perfect sense in one season but not in another season, right? The weather conditions change, and suddenly, I'm not going to wear those heavy gloves, you know, it's just too hot or whatever it is, right?

- Yeah, 100% correct. It would be impossible to write a procedure that covers...well, it would be all...I think it's virtually impossible to write a procedure that would cover every variation of the task. There might be some very narrow work. And, of course, it's going to exist in some very narrow scope work, you know, where there's only maybe two steps, three steps.

But any sort of complex task, there's going to be so many variabilities. And if anything the last two years has taught us is that we can't rely on having an available workforce. So, you know, we can't rely on an available workforce, you know, with COVID. So we're seeing numbers slashed, but guess what?

Demand hasn't. In fact, anything, demand is going up. So people are doing more work with less. We're seeing less availability of parts, and components, and building materials. And so we're seeing people transcend...so in Australia, for example, we've got a real lack of structural timber for our construction industry for building houses, which is one of our primary methods of building here.

So what we're seeing is some transition towards steel because steel was a bit more available, and so there's more steel frame construction happening. But the same builders are building those homes, so they have to transcend how they work from timber to steel. You know, we're seeing all sorts of things happen in that space.

To write a procedure that covers all of that, I don't think you can do it. Breakdowns, you know, equipment not being completely correct for the job. You turn up to...you know, if you're working out in the public and you turn up to...one, you've got the public, for example, and they're all...you know, and the public are always great to work around when you're doing high-risk work.

Those variations you can't account for in our procedure. So workers have to deal with it best they can at the time with the conditions they're given, and the systems of work and those resources and everything else they're provided with at the time, that's basically how they do it.

That's how they make their decisions.

- Okay, so this is a similar question, but I think it's a bit of a different nuance. What's the difference between an investigation that happens before an event versus after an event?

- Oh, well, that's basically almost a risk assessment, right? So, basically, the safety industry has, for all intents and purposes, widely destroyed the purpose of a risk assessment. Risk assessments are always to identify...even under the international standard, are to identify the uncertainty, to identify the unknown.

The only difference between a pre-accident investigation or a pre-event investigation and a post-investigation is the fact the event has occurred, that's it. There's no other difference. All the risks were still there, all the issues were still there. So we can use this same methodology about learning about work as normal in identifying the risk. And in fact, that's the best way to do it because, at the end of the day, the uncertainty is our risk, the unknown is our risk.

And as we tell senior leadership, you can't manage what you don't know and what you don't understand. So it's better, obviously, to gain that knowledge and understanding before there's an event so you can take some action, rather than after event. So there's really not a lot of difference except the fact that we've had a negative outcome, or actually, to be quite honest, we might have had a positive outcome.

So risk is both threat and opportunity. And so events can be success and not success. And that's the other real issue we have, is that we don't spend any time in our organization learning. Well, I shouldn't say we don't spend any. But most organizations don't spend a lot of time learning what makes them successful. You know, they don't.

So an example is we might have a project that's delivered way ahead of time, you know, ahead of budget, you know, we didn't have really any adverse safety outcomes that we're aware of. Our people were...you know, their mental health was great, morale was great. When is the last time your organization investigated that? Because if I'm a leader, I'd love to know what made that successful so my next project, I can put the same things in.

And yeah, I think that'd be valuable.

- That makes a ton of sense. So you mentioned this a little bit earlier, but talk to me more about the role of blame and depth in investigations. So you talked about it in terms of traditional investigations. How does it relate now to sort of newer...the kinds of investigations that you're advocating for?

- So, traditionally, investigations...so there's a couple of parts to this. So, traditionally, investigations, some organizations will treat the individuals involved as guilty until presumed innocent. So we see things like they're stood down from their duties, they might be even sent home. That's at the one end of the scale.

And then some more moderate organizations will keep them working, maybe give them some other duties, maybe not. But their only involvement in the investigation then is they're interviewed or they give some sort of statement, and they provide some information to the investigator. And they hear nothing more about it unless they're disciplined in some sort of formal way or lose their job.

So they're, you know, given a written warning or sacked. Or the only other time I find...or if that doesn't happen to them, they're retrained. Or possibly, the first I find out about is when the organization communicates it to the rest of the business in some sort of information bulletin or safety alert, or some sort of toolbox talk. So that really impacts...there's no involvement from the people there.

It's actually...standing people down creates psychological harm, and the organization is responsible for that, you know. And I don't think a lot of organizations have considered that. You know, you talk to people who've been stood down from their duties and sent home, and it creates mental anguish, and we've inflicted that on one of our employees.

Now, if we're a caring organization, sorry, that doesn't work for me. So that's on the one side. What we're trying to do is create a psychologically safe space where our employees feel empowered and engaged, and wanting to share with us the truth about what's going on in their workplace. So to do that, it's how we view them because that leads to how we then ask our questions and talk with them.

So that's one part. And the second part to that is actually involving them in the investigation. Because who better to help fix something wrong in your organization than the people who do the work, than the people who are involved in the event.

They're the best people to help you because they are closest to the work. So that's the difference we're trying to make. So I mentioned a couple of things there in terms of how we talk to them. So if we view the...say someone had a vehicle accident, very common. Actually, in Australia, incidents involving transport are the highest number of fatalities in Australia.

If we have a driver of a truck that has an incident, if we view the driver as the problem, all our questions will be about the driver. And because that's all we ask about, is the driver, all our solutions will be about the driver. And then our solutions have just left everyone else at risk. So we need to change our questions from about the driver to about the organization because we have got the most skin in the game.

The people with the biggest influence on how the work is done is the organization. So we need to change our focus. And that's one way of creating that psychological safe space. So when we talk to people involved in incidents, we need to talk to them about the work. And that's where we start.

So if I was to interview someone involved in some sort of event, I talk to them about their job, first of all, I ask them about their job. Tell me about how you work, what do you do with your work? How does it work? How does this task work? Walk me through it. Describe it to me. What's a great day look like?

You know, those sorts of questions. You know, what's out of your control? When you're doing that task, what do you have no control over? When do you have to adapt? You know, when don't things go well and you have to change how you...when do you have to change plans? Those are the sort of questions we ask. And we get them to give examples, we get them to give stories.

You know, we call it generative questioning because we're trying to generate stories of how they work. We pretty much ignore the event for most of it. And then if the event doesn't come out, and normally it does, 99.9% of the time, it comes out. But if it doesn't, then we might go back to the event. And then we're asking questions along the lines, well what was different on that day?

What were you feeling, you know? We're asking about these sort of questions, and we're trying to uncover those in their stories. What's going on all the time, you know? Do they not have enough equipment? Is it not being maintained properly? Or, alternatively, they have really great equipment being maintained really well, right. But they're being sent to the right job, so they have the right...do they know the work, you know?

Is the planning...what's the planning like, you know? Those are the sort of things we're looking at and trying to get from those questions. So that's the first part. And we find that creates this psychological safe space because everyone has pride in what they do, you know, and they love to talk about their job.

So it creates this comfort with them. We've got to be genuinely empathetic, you know, we're trying to understand, we need to put ourselves in their shoes so that we can understand what made sense to them. So if they're into a role for two weeks, they've had no reference job, no reference point before, it's their first time doing this task, you know, maybe there's not a lot of supervision, maybe the tools are a little bit confusing, maybe the work is a bit complex, we need to understand from that point of view, rather than a grisly 20-year veteran in safety who is full of counterfactuals, "If only they did this," "If only they had done that."

That's the point of view we're trying to get. And that creates comfort, and that creates them the ability and the freedom to tell us the truth about their work. Now, the second part to that is we talk about involving people in investigations. So although some companies try and do this, they're not really doing it well. When we talk about involving people in the investigation, what we're talking about, if you're involved in the event, you know, you might have been a witness, you might have been the person who, you know, something happened to or you were involved in the task, we involve you in the event.

And by that, you help us gather the information, and not just your own, you help us analyze the information. And that's a massive step that's missed by people involving people. And you help us come up with the corrective actions or the actions or the controls. That is engagement, that is involving people in investigation. We do those things, and what that does, it turns around the culture of investigations in an organization.

It creates trust in the process, it creates this transparency there. And what we have is those people, when they go back to the line, they go back to the work, and their workmates and their colleagues say, you know, "You've been away doing this investigation, how was it?" they'll come back with positive things to say about it, which means that those people have positive thoughts about investigations, which means if something happens and they're involved in an event themselves, they're far more likely to report it.

And not just that, they're far more likely to report things before it becomes an incident or an event.

- Yeah, it occurs to me it's like the difference between a team effort of, like, "Look, folks, something went wrong here. Let's work together to find out." And especially that piece about involving them in the analysis. I think that there's a danger in the traditional way of...it's probably unspoken and probably unintended.

But having this, like, "Okay, you tell me what happened, I am the smart person who will analyze and decide." You know, "I will decide the causality of events and choose the punishment or whatever." There's sort of a team effort versus a bit of a power differential, I think, in the two ways of seeing it.

- Yeah, I completely agree. And I think the other side as well is a lack of trust. So typically, in the past, because we're based on this judicial process, we would never let a criminal investigate their own offense, right?

- And that's the same standard that's applied in safety investigations. Oh, we can't let them investigate it because they're going to influence the investigation so they look good, or they don't look as bad, and they'll influence the investigation that way. It's such an outmoded way of thinking, you know.

- They'll act like a criminal, but maybe because we're treating them like a criminal.

- Yes, exactly right. Why wouldn't you start from a position of trust? If we want our workers to trust us, we have to trust our workers. You know, we trust them, you know, sometimes with millions of dollars worth of assets, very expensive equipment, machinery, our reputation, but they make an error, and all of a sudden, we lose trust in them?

It doesn't make sense to me. And that's where sometimes, I think, that disconnect comes in. Both of what you talked about in terms of, like, "I'm the expert in investigations, I'll do this bit. And I'll do it alone, sitting at my desk in front of my computer, right, with a few statements and some training records and some procedures," to actually involving them in and saying that.

We run what we call investigation maturity assessments, where we look at the maturity of organizations' investigations, and cannot tell you how many people we've interviewed in relation to those. And the amount of people who when we ask them about what they think of the investigation process, they say "Well, I don't know, but I was involved in an event three months ago, they present the investigation report, and none of that happened. You know, they've got a basic thing right, and then that's about it, nothing else happened. And the rest is made up."

- Yeah, which is obviously not going to engender any kind of trust.

- No. No.

- So you just mentioned investigation maturity, and I actually wanted to ask about that. What kind of outcomes could be expected from what you would characterize as sort of a mature investigation process?

- So some things we've talked about so far. So firstly, that we have...the investigation includes the people who do the work, and the analysis, and the action. So a mature investigation process has that. It looks beyond...it's of sufficient depth to identify what we call systemic organizational risks. So in that space, what we're looking for is beyond the superficial organizational issues that we see.

So quite often we'll see investigations which will say the root cause was the worker wasn't trained, and then the action will be train the worker. Well, that's fascinating. That's a start point for me. If the worker wasn't trained, why wasn't the worker trained? You know, was worker not trained because we didn't have a training needs analysis?

Or the training needs analysis doesn't match the role description? Maybe there were no role descriptions. Maybe the training department is not resourced enough. Maybe we didn't know we needed to train someone in that particular task. Why did we not know those things? Why weren't those things in place? And trying to, like, really dig into why that organizational issue exists in the first place.

If we're talking in relation to training, if our training system isn't providing us with trained competent workers, that is a systemic issue because it's not just this one thing, across the board, it could be involved.

It's like purchasing. You know, we didn't buy fit-for-purpose equipment. That is superficial. The deeper question's, well, why didn't we have fit-for-purpose equipment? Well, because purchasing doesn't talk to operations. Why doesn't purchasing talk to operations? Well, purchasing is one person working 70 or 80 hours a week, trying to keep up with paying invoices and buying stuff.

And they've got no time, they just go on Google, Google something, pick it on price, it turns up at the warehouse, "There you go. There's your equipment." There's no analysis there. That's a systemic issue because if we're not providing fit-for-purpose equipment across the organization, that affects our capacity to be safe as an organization. So when we're looking at maturity of investigations, we're looking for that depth. And probably the most important thing is what we're looking for is investigations that reduce systemic risk.

So actually move the risk assessment downwards, right, make the risk more tolerable. That's what we're looking for. Are they actually reducing the organization's risk profile? And also, on the flip side of that, where they've identified success, they've identified opportunities to implement further success in the business.

So those last two points really point me to an organization that has a mature investigation process.

- I think...you know, you've been in this game for over 20 years now. Do you think that you see a difference in how...clearly there are still investigations that are superficial or blame-based or that sort of thing?

However, if you think back to when you started till now, do you see the needle moving at all or?

- Yeah, we do. So we do see the needle moving. A lot of organizations are trying to move to identifying organizational issues, the problem is they're still not to the depth we need.

And it's a bit of a bookend, actually, what we're seeing. So a lot of investigation reports, we'll see, you know, we've identified these system issues at, say, the exec summary, this is what we're seeing. And then in the findings, corrective actions, we'll see some organizations [inaudible]. What we're not seeing is that applied in the middle. In the middle, in the report, in the sequence of events, in that sort of long-form story of what happened, we're seeing a lot of blame in those.

So, you know, when the manager gets it, there's, you know, still this focus on blame. But probably the most worrying thing...although we're seeing a trend towards organizational issues, the problem is the actions we're seeing are really weak. So we're seeing a lot of training actions, we're seeing a lot of rewrite our procedure actions or review our procedure actions.

We're seeing a lot of, like, toolbox talks, you know, where we'll put the information in some sort of communication advice out to the broader organization. And that's probably the top three we see in terms of corrective actions, and they do not reduce systemic risk. So our challenge to our listeners today is this.

Have a look at your last four months' worth of investigations, like, the high-potential stuff, right, let's not worry about the low-consequence stuff, you know, high impact, high consequence, high potential. Take out all your administrative actions, so procedures, training, you know, talks, whatever that is, remove all of that.

What's left? And that'll give you probably a really good quick picture of how mature your investigation process is. And by the way, you can also do that on your risk assessments. If you do that on your risk assessment as well, remove all your administrative actions from your risk assessments and look at what's left, that gives you a true picture of your tolerability of risk at your organization.

- You've suggested that organizations are often under-resourced for investigations and that, ideally, they should have a dedicated investigations team. Why do you think that's important?

- So there's a couple of things to unpack here. So firstly, very few organizations have a dedicated investigation team. It's a high cost to the business, and the business doesn't see a return on investment. By the way, we can change that. We can clearly demonstrate an ROI there. So what happens is investigations are either facilitated by safety people or by operations themselves.

Now, the problem with that is we don't budget for it. So there's nothing in the budget that says, you know, when the manager is doing the budget for the year, they don't go, "Oh, I'm going to lose, you know, so many people for so many days to do an investigation." So whenever an event occurs, it's always breaking work, so they've still going to do their normal day job, they've still got to fit it around their normal work and get all that done.

Plus, they've got to do an investigation. There's a trade-off. So we're either going to get to see compromised work performance from their normal job, which is their main role, or we're going to see a compromised investigation, where we're talking time and resources. An example is this. So if you've nearly killed someone in your organization, like, just lucky that someone didn't die, right, think of the resources that get allocated to that.

And it's typically not a lot, especially where you compare it to where if you've been in a tragic circumstances where you had a fatality at your organization, how much money, time, effort we throw into that investigation. Now, if the only difference is a centimeter or a split second in time, what's the difference in how we should approach the resources we spend at that, you know?

We talk about near-miss investigations as being, like, we're lucky, you know, this is a free opportunity to learn. And then we invest almost nothing in the learning from that near-miss. When we should invest a heap of money in that near-miss if it was a legitimate, a centimeter, a second, a stroke of luck.

We don't invest the resources. So you get what you pay for, you know. Leaders are smart, they know that. You get what you pay for. But to try and demonstrate the return on investment is difficult to do and takes some planning. But you can do it, you can do it. If we can demonstrate that a control or an action out of an investigation will actually save someone's life, stop people getting hurt, we can actually work that out in most organizations, what the cost of that saving would be, we can work that out.

Risk is based on finance. Most organizations have some sort of statistical value of life. We can work that out, and we can work out the cost of implementation, the cost of the lifecycle of the control, as opposed to what it would cost us the likelihood of someone losing their life.

We can clearly demonstrate value in that. So that's the first one in terms of allocating resources. And the other thing with that is, we can sort of predict. So most budget is based on what we spent last year, right, and where we spent it. And we can predict what we want to do in the future. Most organizations' trend of incidence is fairly static. So we can actually work out what it would cost us and put it in our budget.

We just don't consider it. We just don't consider it. The other reason I like permanent investigation teams is purely this, facilitating investigations is a perishable skill. Too often I've seen organizations go away and train, you know, almost entire workforces in investigations. And they're lucky to do one in their career, they might do one or two, and this is the operation side.

And they forget, like, it's not their day job, they got normal work that they do, and they forget. And so it's a perishable skill. If you wanted to see the best return, if you could afford to have a full-time investigation team, that would be my advice. If you can't, then have just a dedicated pool of people who are your specialist investigators and they do them more frequently.

They might have a day job, but we account for that in our budget, that they're going to be pulled away from that, we provide them backup so they're not stressed and placed under production pressure to do both their full work plus the investigation. We can plan for that, we can resource it properly. And we'll get far better outcomes with experienced investigators than we will with amateur investigators.

- As you're speaking, I'm thinking...it sounds like...and I don't know, this is my ignorance. Do most companies have, like, a risk assessment team? Because it sounds to me like risk assessment and investigations and the way you're discussing is the same thing?

- Exactly the same thing. So a lot of organizations might have a risk team, but they're predominantly based around finance. So risk, predominantly in organizations, big organizations, belongs to finance, and we're talking about enterprise risk. When we talk about health and safety, there is the odd organization that might have one or two in the risk team in health and safety, but they're more looking after the system.

In terms of facilitators of risk assessments in there, again, it's breaking work again, you know. And too often, that risk assessment is done very quickly. And I've seen so many done at a desk by the safety professional, right, or safety advisor, whatever it is, at a desk, by themselves, not talking to people, working it out, and then going around and getting someone to sign off on it.

And those things are an administrative tick and flick. To be quite frank, they're doing nothing to protect your organization's health and safety risks. We need to understand to do proper risk assessments, it's even in the standard, we need to understand the context of work, and we need to identify the uncertainty. Too many risk assessments I see do neither of those things. There is no explanation on the context of work, and they certainly don't look for uncertainty, they just repeat what the known risks already are.

And then we end up in these rooms with cut and paste, you know, with an Excel spreadsheet, or a bowtie, or whatever the methodology people are using. And the boring people don't want to go to them. No innovation comes from risk assessments. Well, you know, I shouldn't say no, I shouldn't be absolute, but very little innovation ever comes out of risk assessment, all that comes out is a repeat of everything else we've done in the past.

So yeah, the way we do risk assessments is almost zero value except for giving this perceived protection to leadership that they've assessed risk when actually they haven't.

- So when you talk about looking for risks that we don't know about it, and truly investigating, one of the methods, again, you talk about getting the stories of work or identifying work as normal. How would you recommend...like, practically speaking, how do you go about doing that? You talked about generative questions, is there any other method?

- Yeah, so the best way is generative questioning, it's probably where you do it and how you do it. So there's no wrong [inaudible]. Like, if I'm going to ask these questions, I want to do them where the work is because I can ask my favorite, show me how you do this task, right? So I can observe the work being done, I can talk to them while the work is being done.

And I can develop that deep understanding of the context of their work. So that's probably the best place, is where the work is being done. Filing that, small workgroups are the best way to go. And even approaches like learning teams, which are fantastic, you know. We get people in that do the work, various...so if we've got a manufacturing plant, it might be the people who operate the manufacturing plant and the people who maintain the manufacturing plant.

We get them in a room and we work through the task, and we ask those generative questions to that work group. And it doesn't matter if it's an investigation or risk assessment, you can do it at the job site where they're working, or you can do it in a small room. But you've got to create that psychological safe space. And that means sometimes giving leadership the boot, we don't want them there, you know. We want them there at the start, "Thank you, I want to know everything, tell me everything. I'm going to leave you in the facilitator's hands. And I'm really looking forward to coming back and letting me know what you've come up with."

That's what we want from our leaders and then providing the resources and the space to do it, and the support. And then just let us dig in, you know, with the people who do the work, you know, that's how we do it. So it can either be on the site where it's in or in a room with a group of people.

You know, there's no wrong or right way to do this. I've seen learning teams work with, like, 50 or 60 people, my preference is under 10. Because that allows...you know, my preference is probably, you know, 4 or 5, to 10, in that sweet spot, so about 8 maybe, and we just really start to explore that. But having said that, if you can't get everyone together, then just go out and hit people up one by one, you know.

The worst thing you can do is put someone in a room and put the tape recorder on and write out your notes and all this sort of stuff. We're not CSI.

- Yeah, it occurs to me that also it would be helpful to have them show it to you because if you have someone describe something, like let's say they say, "And then I twist the lever," but then they show it to you, and, actually, you're rotating, not twisting. You know what I mean? Like, just little nuances of language, sometimes it's helpful, I imagine, to watch.

- It's invaluable. And you can't get it from CCTV, right? CCTV is so two-dimensional. Watching them do something and demonstrate something is great because, as you said, twisting, or rotating, or however they're doing it. But what you might see is that the very heights of the workgroup, you know, the very size of the workgroup could also impact how they do that task.

Some might have to stretch, some might have to crouch, some have to bend over. So discovering those things is really valuable. But if we can't get in the workplace, what I generally try to do...whenever I'm facilitating anything like this, even risk assessments, I don't use a computer. I use whiteboards and flip charts and things like that.

I'll get them to draw it. I love getting people to draw things. If I can't be at the worksite with them, my next best thing is, you know, maybe we can put some pictures up, some video up, and they can explain it, walk me through it, that's fantastic help. And also get them to draw it. And the reason I like people drawing things out is because whilst they're drawing, they're telling me a story, and I get both.

And what it does is it really crystallizes what they're saying because they've now got to transform this into a picture. So it makes them more think through and actually makes...it encourages and enables them to put things in the right perspective, in the right place, in the right order. Such a valuable little tool that we use to do that is drawing.

- I can imagine it makes them think in a more detailed way than they would normally have to because for them, you know, they don't have to think about it, they know.

- Get's it out of their head, right?

- Yeah, exactly, which is where you need it.

- It's no good stuck in there, it doesn't help us at all. And actually, I find it quite cathartic, too, by the way. Like, it's actually a very cathartic exercise. Them talking about their work, and explaining their work, and drawing their work, and getting these things off their chest, they find very cathartic. So it really helps with that mental space, especially if they've been involved in an event, because they're talking about it.

So we find that really valuable.

- Yeah, I would imagine it helps them really feel seen in what they're doing.

- Seen and heard.

- Yeah. So how should investigations or their outcomes ideally help managers?

- Every investigation that goes to a manager, the manager should be able to honestly answer this question. What have I learned that I didn't know before? Now, if the manager learned nothing that they didn't already know, that investigation probably has a few issues.

Or why do we even do the investigation in the first place? I would question the value of that, why we even do the investigation, as well as if we did it properly or not. We can't manage what we don't know and don't understand. So the more information we give to managers, the better decisions they'll be able to make. Because at the end of the day, everything that a business organization's done is governed by how resources are managed.

So how much money, time, effort, people, equipment, whatever we put into a process is decided by leaders who move resources around. Now, to enable them to best place resources and best spend resources, they have to have the best and most accurate information possible, with really good recommendations to assist them. Because they're not experts in the work, so they need really clear understanding of what's happening in their business.

A real understanding that these are the things you didn't know about, but here's some really good recommendations that came from the people who do the work that will address that. And quite frankly, most investigations we see...and safety is just an outcome of work, a lot of the really good investigations we see, 90% of the actions actually improve all of the work. They improve cost, efficiency, not just safety, they improve a whole heap of other stuff at the same time.

So that's what managers should be looking for. If they can't honestly learn nothing, that's a poor investigation. If they learned something they didn't know about and they can then take action on that, good investigation.

- And a good way to convince higher-ups of the ROI of investigating safety as well.

- And that's sometimes where I think investigators fall over as well because we'll...so we'll do an investigation, we'll put it forward. The manager will look at it and go, "Well we can't afford that control, we're not going to do that. We're not going to do that action, we're not going to do that action." We need to start treating our investigation reports like business cases, you know.

We need to ensure there's some business case element to our investigation report that clearly demonstrates the value of putting this in. We need to create a clear link between the action and the reduction of risk, right? And if we do that, we're far more likely to succeed in the managers taking on board our recommendations and implementing them than if we, you know, just put simple stuff that we can't...you know, that doesn't really make a difference.

- Yeah, I think that's excellent, very practical advice. What core skills does a good investigator need? So if we have listeners who are interested in specializing in investigations, what skills would you recommend they develop, and maybe what's the best way to develop those skills?

- So I think the biggest, your soft skills. Investigators need to have really good soft skills. They have to have an innate empathy for people. And most people in safety tend to have that innate empathy, so that's not too much of a stretch.

But they have to really focus on their soft skills. And they need to focus...they need to truly believe that they will achieve better outcomes by investigating the work, learning about the work than the person. So I think those soft skills. So the way to get good soft skills is to, you know, be the master of your own professional development, you know.

Like, read, like, Todd Conklin's books on, you know, the "New View of Safety" and human and organization performance, you know, "Pre-Accidents Investigations." Read Sidney Dekker's books, you know, "The Field Guide to Safety." Listen to podcasts, you know, like, try and chase down this information, it's out there. Do some courses, you know, whatever you need to do, improve your soft skills, then practice, practice, practice.

Don't wait for an investigation to go out and practice your soft skills. The first time you talk to your workforce shouldn't be as a result of an event, you know, you should be asking those same questions every time you go into the field. So good investigators do not just spend all their time just asking questions about investigations. They'll look for downtime, or they say normal work, predominantly because, you know, very few teams have investigation teams, out on the field, asking about normal work, right?

What's a good day look like? Walk me through the task. Learning and building that soft skill repertoire. So I think that's number one. Attention to detail and having that real attention to detail. That genuine curiosity, you know, being genuinely curious. Building relationships with the stakeholders at a high level, you know, and build personal relationships.

So too often we're trapped in this work relationship where we only talk about work at work. Make the time to find something personal about. You know, what food do they like to eat? Do they go camping?

Do they exercise? You know, what's their family? Family is such a great in with people. You know, and practice those and find out. And make that the first thing you talk about whenever you talk to someone, you know. So, you know, like, even emailing. So my first line in email to people I work with is about something personal.

You know, how was your weekend? What did you get up to? Or how's, you know, your partner and kids? Or, you know, how about those football team, you know, how did they go last night? Because we both follow the same football team. Build that first and then it makes it easier to ask for stuff. Because in safety, we don't own anything, right?

So we always need operations to realize you're nearby, and so do that. And the challenge is someone you don't like or someone you don't have any relationship with at all. The challenge for the listeners, pick someone that you have a struggle with relationship and build a personal connection, right, and see the dynamic of that relationship change. Be curious, and don't be linear with your thinking as an investigator.

Don't get trapped. So one of the big issues we see is people have a system of investigation. So it might be, you know, TapRoot, might be ICAM, it might be some other RCA type that they do, and that don't be trapped by outcome. It's the same with risk assessments, people are trapped by the outcome, this spreadsheet that they may use, so that they let that govern the process of how they do their discovery.

Don't let the template that you have to put things in drive how you discover what goes in there. Discover and then make the template work or change the template if that's not working for you. So don't get trapped by that. So yeah, the soft skills, so appreciative listening, you know, generative questioning, practice those skills, those are the most important skills you'll have as an investigator.

And probably within that set is acknowledge that you will always have a bias, right? Because investigations are a social construct, they're subjective in the end, they're always going to govern by our own lived experience. So it's minimizing the impact of that and understanding and recognizing where your bias or lived experience might be impacting how you ask questions.

So just be mindful of that, right, and hold that mirror of self-reflection up.

- As you were speaking, again, I was thinking, the good thing about all of those skills, curiosity, empathy, developing relationships, is that you can practice them at any time. If you are human and you relate to other humans, whether it's in a workplace situation or not, you will get plenty of opportunities to practice.

- I love that line. Be a human. Like, just be a human. Like, it's not hard, right? Be a human. Like, we're not a cop. We're not a cop.

I left those days behind years ago, not a cop. I'm not there to do a regulator's job. At the end of the day, what I want from my investigation is to reduce the actual systemic risk within my organization to make it a safer place to work. That's my outcome. If I've done that, I've achieved something. I can be proud of that.

And however, how we get there, is by harnessing your people, you know, and that's what it's all about.

- Great. Well, I have a few questions that I ask all of the guests at the end that are just a little more generic, a little less about the topic at hand. So I wanted to ask you, what are the core human skills...okay, so this is almost exactly what we just talked about, but I'll ask it anyway.

- Please.

- If you think of it not necessarily in terms of investigations is, what are the core human skills or non-technical skills that are the most important to develop in tomorrow's safety professionals? And I'm thinking in terms of people who go to programs, like diploma, certificates, universities, to train to become safety professionals. Where should those programs be looking in terms of those skills?

- So we've talked about the soft skills. You know, teaching people how to ask better questions, I think that's the number one thing. I think defining the role of what a safety professional is, I think they could do a better job there. We're highly focused on compliance when really, we need to be focused on facilitator.

So I think facilitation skills are key. I would encourage any safety professional to really develop their facilitation skills. How can they bring...you know, identify help. So how they can help organizations discover what their issues are, firstly, not assume what their issues are.

Because too often in safety, we come and say, "These are your problems." How about we discover from them what their needs are? Then facilitate, then connecting with the right people to assist with fixing those needs. Or it might be the organization help build the capacity within the organization to fix their own problems.

So I think as a safety professional now, we've got to move from compliance. And look, there's always going to be a bit of that, you know, that's part of our role. But I think it should be like a minor part of our role, a major part of our role should be about facilitation. Facilitating organizations improving their own capacity and capability to improve their work. And notice I said work, not safety, right?

Because we know it's just an outcome, right, of the work. So those skills, I think, are really important. I think the big concern for me is that a lot of safety people stop learning once they either leave their formal program, which just gives them a common language, right? They stop learning and then all they ever learn is from their own internal organization's way of doing safety.

So that's probably the second major part for me. If safety wants to be treated as a profession, like engineers, and other professionals like that, but in organizations, then we need to act like professionals. So we need to have those characteristics and those traits.

So professional self-development is a massive part. So, you know, I am constantly looking at new papers online. I'm very fortunate I have a friend who sends me stuff and does a lot of that so he knows what I'm interested in and he picks stuff out for me. I'm constantly watching and listening to podcasts, and webcasts, and webinars, and things like that. I go to conferences and listen to other people talk.

And I'm talking to other...and building a network of people. So that's probably another skill I'd like to see being taught at institutions, is networking skills. How to increase and leverage networks, I think that would be a great skill to have as well.

- So a little more personal now. If you could travel back in time and speak to yourself at the beginning of your career, and you could only give young Mark one piece of advice, what do you think that might be?

- You don't know anything. My younger self thought he knew everything. It would be to go back and slap myself, and say, "You actually don't know anything. Start asking me the questions."

- That's great advice. You should come talk to my kids.

- Oh, I was young, anyway, the arrogance of youth.

- You've mentioned a few resources as we were talking throughout the questions. But I do like to ask at the end do you have any practical resources that you would suggest to safety managers? So that could be a website or a concept, it could be a book.

- Okay, so there's probably a few. Todd Conklin's "Pre-Accident Investigations" is a great book. Sidney Dekker's "Field Guide to Safety," I'd seen it's...I'm not sure what edition it's in with Sidney at the moment. But that's a good book. There's a podcast out of Australia called "Safety of Work."

And it's by Dave Provan and Drew Rae. They're very good. And they actually break down scientific papers. So what we're trying to do in safety is look for empirical science-backed data for our interventions. So they break down a lot of those papers that are out there at the moment.

And so there's a lot of really good information there. So they're probably the other ones. In [inaudible], I think, there's a book called "Paper Safe" by Greg Smith. Now, I know this is an Australian book, it's based out of Australia. But he's an Australian lawyer, but he's a specialist in work health, and safety.

That "Paper Safe" book, get a copy of that, see if it applies in your country. Because basically, it tells, from a work health safety lawyer point of view, like, one of Australia's leading advocates, about how your procedures aren't going to keep you safe in court as a leader. It's what actually your people will do. And I recommend to all my clients that they actually buy a copy of that book and give it to their board members, their CEO, and every member of their leadership team to read.

Because I think they need to get that understanding because too often they think paperwork is what's going to save them, and it's not. So those are there. And look, you can flip to my website, I've got a few webinars there if people are interested as well.

- Oh, well, that was my next question, is where can our listeners find you on the web?

- So look, reach out to me on LinkedIn, I'm on LinkedIn. We've got our website, www.investigationsdifferently.com.au. We're based in Australia, but we travel the world. So yeah, we've got a few resources on there, some webinars and some articles. So that's it.

And if you want to make contact, reach out on LinkedIn and say hello, I'd love to hear from you.

- Great. Well, that's all the time we have for today. Thanks so much for joining us, Mark. And thanks to our listeners for tuning in.

- Well, thank you very much. I've really enjoyed it, and yeah, it's been great to be here.

- My thanks also to the "Safety Labs by Slice" team, who find fascinating guests and make the podcast run smoothly every week.

- Thanks a lot. Appreciate it. ♪ [music] ♪ - Safety Labs is created by Slice, the only safety knife on the market with a finger-friendly blade. Find us at sliceproducts.com. Until next time, stay safe.

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