Ep 5: What you find in investigations isn't what you fix

Conventional logic suggests that we fix the gaps that we find in investigations. But is this the case?

Is the investigation process more a socially constructed game of sociopolitical whack-a-mole, finding and fixing the things that are easily solved or understandable, or tolerable to the organisation?

Lundberg, J., Rollenhagen, C., & Hollnagel, E. (2010). What you find is not always what you fix—How other aspects than causes of accidents decide recommendations for remedial actions. Accident Analysis & Prevention, 42(6), 2132-2139.

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Intro/Output "Dark Synth Wave" by ElephantGreen(PixaBay.com)

Episode Transcript

(00:06):
We investigate, we analyse and we identify contributing
factors. Then we recommend fixes.
Simple right? Or is it our investigations such
as the truth or more a game of socially negotiated whack, a
mole influenced by competing socio political influences?
Less about fixing issues and more about systemic pressures

(00:28):
and biases shaping what factors we construct, find or dare to
find. Let's explore how aspects other
than causes influence what we find and fix.
Good everyone. I'm Ben Hutchinson and this is
Safe as a podcast dedicated to the thrifty analysis of safety,
risk and performance research. Jump onto safetyinsights.org.

(00:48):
More research. Today's study is one of my
favourites titled What you find is not always what you fix how
other aspects than causes of accidents decide recommendations
for remedial actions by Lundberg, Roland Hagen and
Hornagle published an accident analysis and prevention in 2010,
so for methods they interviewed 22 accident investigators to

(01:11):
understand the hidden constraints that pull
investigations away from the ideal assumption.
What you find is what you fix. In essence, how does the same
organisational context that contributes to accidents also
constrain the investigation process, shaping the causal
factors that are identified for mediation?
So what do they find? While investigators believe that

(01:34):
they followed the what you find as what you fix ideal, the data
showed that analysis and the design of actions are heavily
influenced by practical constraints.
As the authors put it, this results in the reality that what
you find is not always what you fix.
There's too much to cover in this paper, but here's a few of
the key findings. What you fix depends on what you

(01:54):
can understand. This relates to the
investigator's experience and their knowledge of the task.
This constrains what they can actually find and fix.
What you fix depends on what youcan afford to investigate.
Resources and time are major limitations.
What you fix depends on what youcan find.
Investigators struggle to speak with all of the relevant
stakeholders, especially outsideof their own company.

(02:16):
What you fix depends on what youdare to find.
Management isn't always open to criticism, which can hinder
examining management influences,echoing findings from major
accidents like the NASA Challenger shuttle disaster.
What you are able to fix dependson what you find or when you
stop looking. Investigations often stop based
on arbitrary stop rules, like ticking off all the facts or

(02:39):
identifying a set number of fixes, or stopping where you run
out of time. They do this rather than a
comprehensive understanding or deep dive.
What you know how to fix is whatyou fix.
Investigators might gravitate towards problems with known
remedies, even if more complicated but effective
strategies exist. This can lead to fixing what's

(02:59):
easy, not necessarily what's best.
What you fix depends on what is easy to understand and known to
work. This prioritises readily
available solutions and established rules, even if
they're not the most targeted orsuitable for that context.
What you fix depends on what you're going to fix anyway.
Sometimes investigations simply validate preconceived fixes or

(03:22):
fixes that support their existing worldviews.
So we find and fix things we were going to find and fix
anyway. What you fix depends on what
someone else decides. Recommendations may be overruled
by higher ups and those with power, but also by people who
might actually lack direct familiarity with the issues.
And what you fix depends on the cost benefit balance.

(03:43):
Despite claims for the contrary,cost often influence the types
of actions taken, sometimes leading to less expensive
temporary fixes. So there's a bigger picture.
The authors argue that while thorough investigation methods
are still useful, they're unlikely to prevent most of the
factors mentioned by these investigators from leading the
investigation away from that ideal of what you look for is

(04:05):
what you fix. Said differently, these
influences are at play in all investigations, regardless of
the methods used. You might think that you're
immune from these issues, or that using method A isn't
susceptible, but these sorts of factors in some capacity in
configuration likely exist in all investigations.
Interestingly, no investigator blamed poor investigation

(04:29):
methods as a constraint. Instead, they highlighted these
external and internal pressures.This suggests that Acts
investigation isn't purely rational, nor is the choice of
actions. Perhaps, as the authors
pragmatically suggest, it is actually irrational to consider
the possibilities and constraints of a situation when
selecting fixes. Also, it's not necessarily based

(04:51):
on flawed thinking. Many of these constraints are
sociopolitical, not cognitive biases.
So what can we make of this? Besides the obvious of
considering investigations as socially negotiated activities,
another implication is how we treat the findings.
If we see investigation findingsas simply some areas for
improvement, then happy dance. But if we see them as purveyors

(05:13):
of reality, confirmation that our systems are working and risk
are acceptable, then I think we really need to reconsider.
Paraphrasing Andrew Hopkins, badnews doesn't travel well.
So what were some limitations? Of course, with just 22
investigators, sample size is always a consideration when
considering. How generalizable are the

(05:34):
findings? However, other research does
support the investigations are indeed affected by various
socioolitical influences. That's it.
On Safe as I'm Ben Hutchinson and hoe you found this useful.