Top 10 Incident Investigation Mistakes
Top 10 Incident Investigation Mistakes In 1994
At the first TapRooT® Summit in Gatlinburg, Tennessee, in 1994, attendees voted on the top incident investigation mistakes that they had observed. The list was published in the August 1994 Root Cause Network™ Newsletter (© 1994).
Here are the top 10:
- Management revises the facts. (Or management says, “You can’t say that.”)
- Assumptions become facts.
- Untrained team of investigators. (We assign good people/engineers to find causes.)
- Started the investigation too late.
- Stopped the investigation too soon.
- No systematic investigation process.
- Management can’t be the root cause.
- Supervisor performs investigation in their spare time.
- Fit the facts to the scenario. (Management tells the investigation team what to find.)
- Hidden agendas.
What do you think? Have things changed much since 1994?
What Are the Top 10 Investigation Mistakes in 2023?
It has been almost 28 years since we published this list. If your management supports using TapRooT® RCA, you should have eliminated the 1994 top 10 incident investigation mistakes.
What are the biggest incident investigation mistakes across your industry that you observe today?
Are they on the list above?
Leave your votes as a comment. Then we can see the kind of progress we have made…
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When? April 24-28.
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All investigative tools suffer the same fate. Change the senior staff and so does the outcomes. That’s human nature, vested interests or perceived vested interests in the outcome.
Thr suggested mistake is using internal people for the investigation. Therefore bias protectionism and limited interference would be removed, assuming the correct protections are in place for the Contractor.
Thanks for your comment.
I believe it may be the nature of companies with a blame oriented vision to be protective (cover-up) what happened. But with an improvement-oriented vision, you can use a systematic process like TapRooT® to find and then fix the real root causes of problems. See https://www.taproot.com/what-vision-for-root-cause-analysis-does-your-company-have/.
If you can develop a learning organization with an improvement-oriented vision, root cause analysis can flourish and performance will improve. I think this works better than having outside investigators.
If you have outside investigators and a blame vision, blame will still be the main outcome.
Outside investigators may be needed to help with complex, controversial, or client complaint investigations to provide a different (or in the client investigation – independent) set of eyes.