How to Pinpoint and Fix Causes of Incidents in 6 Steps

By Tom Biles – VP, Risk Control January 24th, 2024

The most commonly used safety incident analysis methods are overly complex or focused on assigning blame — and they don’t typically help companies make work processes safer, according to Dr. Jake Mazulewicz, director of JMA Human Reliability Strategies. During Captive Resources’ January Risk Control Webinar, Mazulewicz proposed an alternative: an Event Review program that improves workplace safety by growing human safety expertise and a safety culture of mutual trust between executives and workers. Read on to learn the program’s six steps.

Based on Learning, Process Improvement, and Trust

Mazulewicz presented Event Reviews to the audience of safety leaders and other representatives from group captive member-companies as an improvement over methods such as the 5 Whys and the Root Cause Analysis (RCA). He pointed out that modern work requires more constant teamwork, communication, adaptation, and in-the-moment decision-making than repetitive, individualized Industrial Revolution Era manufacturing jobs did.

As a result of this evolution, incidents rarely have a single root cause or culpable worker, and methods such as RCA tend to “fix the blame, but not the problem.” Event Reviews, in contrast, regard errors as signals of underlying problems rather than failures and are designed to build trust, improve processes, and grow employees’ accident prevention expertise.

He stressed that Event Reviews are better suited for incidents involving human errors, such as miscommunication, than incidents with complex mechanical failures. Also, they are more helpful in learning and improving safety than building a legal defense, he said. He advised the audience to use an editable document for each Event Review and then detailed the six steps.

Step 1: Lead an After Action Review

He described the first step, an After Action Review (AAR), as a non-punitive, semi-structured, post-incident debriefing. Mazulewicz — a former firefighter, emergency medical technician (EMT), and paratrooper — pointed out that military teams, firefighters, EMTs, and many companies have used AARs for more than 30 years. The safety leader gathers the event participants, makes it clear that this step will be non-punitive and learning-based, and solicits answers to four questions:

  • What did we set out to do?
  • What did we actually do?
  • How did the situation turn out the way it did?
  • What will we do differently next time?

In some cases, this step reveals both the desired end state and why the event prevented the end state, and a one-page incident report is sufficient. If the event warrants a deeper analysis, the leader should move to Step 2.

Step 2: Write a Target Question

The Target Question should steer the organization toward practical, real-world solutions, not away from failure scenarios. It should avoid ABCs — Assumptions, Blame, and Counterfactuals (i.e., comparing actual actions taken to ideal ones) and focus on the future, not just the past. Mazulewicz drew on a famous incident to show how to write an effective Target Question:

  • Don’t ask, “Why did the Titanic sink?” or “Why didn’t the captain and crew take better actions to save more lives?”
  • Do ask, “How can we maximize safety on passenger cruises based on what we learned from the Titanic incident?”

He added that revising the question as details emerge might be necessary.

Step 3: Create a Timeline and Find Anomalies

The safety leader should create a concise event timeline in one or two pages, including a brief description of crucial event milestones and the times of the day, Mazulewicz said. In the process, they should identify questions and ideas and highlight three to seven anomalies (without including any ABCs).

Step 4: Ask Questions about Each Anomaly

Mazulewicz suggested creating a table with six standard questions and blank answer fields for each anomaly:

  • How do frontline experts usually perform this task?
  • What individual actions led to this anomaly?
  • What situational factors led to this anomaly?
  • What supervisory factors led to this anomaly?
  • What organizational or cultural factors led to this anomaly?
  • What are suggested process improvements?

Also, the safety leader should add any relevant follow-up questions specific to the event or organization. These Q&As should be projected during Event Review meetings spearheaded by the safety leader who maintains trust, pace, and focus and asks tough questions. A scribe should assist the leader and fill in the answers in real time.

Step 5: Distill 3–7 Best Process Improvements

Mazulewicz provided guidance for developing three to seven actionable process improvements. He said process improvements should not consist of documenting more “paper safe” procedures or increasing penalties for managers and employees involved in incidents, which increases fear and decreases morale and truth-telling.

Mazulewicz also cited two types of effective process improvements:

  • Designing processes for post-incident organizational resiliency breeds deep cultural changes rather than superficial behavior changes, and it can engage front-line experts to share their ideas.
  • Having workers practice live-action, hands-on emergency drills builds their confidence and skills for future emergency responses.

Step 6: Share, Apply, and Follow Through

Mazulewicz urged safety leaders not to provide the executive team with a lengthy Event Review report unless one is requested because they are rarely read. Instead, he said, write a longer report for future reference, but share only a condensed briefing with the executive team.

The briefing should summarize information from steps 1–5. He stressed that the report should include those responsible for implementing the process improvements and target dates.

About the Webinar

This presentation was part of Captive Resources’ Risk Control Webinar Series — regular installments of webinars to educate the group captive members we work with on topics like workplace safety, organizational leadership, and company performance. The thoughts and opinions expressed in these webinars are those of the presenters and do not necessarily reflect Captive Resources’ positions on any of the above topics.

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