There is general agreement that the purpose of accident investigations is to learn the truth about an incident and learn from it to prevent future loss of life, property or health of individuals. This paper proposes that there is a basic misunderstanding of the nature of such “investigations” that limit their usefulness in the prevention of future significant injuries and fatalities. It also proposes a shift from investigation to sensemaking with the leader as listener.
Basic Misunderstandings
First, accident investigations are seen as a scientific and academic analysis of the facts that occurred during an accident. The task is to identify the root cause of an accident to make recommendations or take corrective actions to prevent the future recurrence of a similar event.
This linear cause and affect approach does not take into account the varied interpretations of reality that are typical in the human experience. Consensus or majority vote that something is true is no guarantee of being right. For example, up to 48% of crime eye witnesses pick the wrong suspect out of a line-up. It is far more accurate to see an “investigation” as a sensemaking effort to approximate reality rather than a fact-finding activity.
Sensemaking, Learning and Inquiry
According to its originator, Karl Weick, sensemaking is literally the act of making sense of an uncertain environment. People organize data until a “sensible” explanation arises, or at least an explanation understood well enough to enable reasonable decisions (1995). There is no claim that this process arrives at a single “factual reality.” In fact, Weick wanted to draw attention away from decision making towards how people interpreted the decisions and acted on them. The process of sensemaking is continuous, a fact that frustrates managers who believe a matter is closed.
The goal is to gain enough understanding of a situation to be able to take helpful action. “In this complex and dynamic process members shape and are shaped by events” (Weber & Manning, pp. 238-239)[1]. It is a process by which people give meaning to experience. So, there is nothing objective about an accident investigation. Each person brings their experience and assumptions to shape the meaning of the event and potential actions to be taken.
Adopting such a perspective changes the nature of accident investigations. It is no longer a search for facts, but rather an open-minded pursuit to understand the individual experiences of each participant in the process. Such an approach implies that the information we need to prevent the next serious accident or fatality is always within the people who do the work. Getting that information is often a challenge because the knowledge may be unconscious. Or, people may not be willing to share it with the investigators or people in authority for fear of repercussions.
Thus, facilitating sensemaking that leads to solving complex problems such as preventing SIFs takes a leadership-level listening. Trust and open communication are at the heart of such an environment. They are the key to maintaining a constant flow of information that provides the faint signals and precursors of incidents.
Case Example
After a significant injury or fatality, it is often shocking to realize how much information was available that would have prevented it. A widely publicized example was the accidental, but fatal, shooting of a camera person on the Rust movie set in 2021. There were many procedures to ensure that guns were not loaded before they were brought on to the set. In this instance, a gun thought to not be loaded had previously been fired accidentally. So that near miss had already raised questions about gun safety. How could it be that another loaded gun got through the system and this time tragically killed an employee?
It would be tough to make sense of such an event because in retrospect it seems so preventable. The people involved would have to be willing to sense-make around emotional and possibly threatening topics. Unfortunately, the first action was to fire the person in charge of gun safety thus making it clear that unforgivable mistakes were made.
It is unlikely that a company could avoid not firing the person most directly responsible for checking the gun and pronouncing it safe. So what could be done to re-open the channels of communication in circumstances where trust is lost and only fear and loss exists? What should a professional focus on when conducting an investigation in these circumstances, so they might obtain useful information? It is a perfect opportunity to facilitate a sensemaking session and lead by listening.
Leading by Listening
Leading by listening helps leaders, managers, safety professionals and accident investigators gain greater access to information that reveals the contributing factors to an incident. It is not ordinary listening. It is listening at the level attributed to the best leaders and transformational mediators. The goal is to learn from mistakes rather than place blame. The LISTEN model provides interviewers/facilitators with behavioral guidelines to shift the situation from blaming to learning. What would it take to reach this level?
Psychological research makes it clear that if we want to maximize engagement and involve employees in the solution to a problem, we need to meet their motivational need to be safe from blame, ostracism or other personal loss. The LISTEN model teaches participants to better leverage the principles of psychological safety and effective communication to acquire the best information possible to improve safety and overall performance.
L.I.S.T.E.N
This model is based on five social behaviors identified by neuroscience as factors that increase an individual’s ability to reduce bias, and identify important data. Their presence during interviews is desirable because it helps people to recall more information and reduces the fear of sharing it. The five behaviors begin with letters that spell out L.I.S.T.E.N. They are:
Learn
Individuals employing factual listening are attentive to new ideas and data, and are accepting of any differences from what they already know. They are learning new information. The outcome is that their opinions or views on a situation may be altered by new information which is now available to them.
Inquire
Ask, don’t tell. Edgar Schein, author of Humble Inquiry, makes many brilliant points about the value of asking questions rather than giving information. “Ultimately the purpose of Humble Inquiry is to build relationships that lead to trust which, in turn, leads to better communication and collaboration.” We need to ask questions beyond what we think is enough to start giving advice or drawing conclusions. Even a silent pause is helpful because it allows the other time to bring up thoughts not yet spoken.
Save Face
Saving face preserves our sense of status. It is the need to be viewed as competent and a valued member of the group. David Rock, author and neurobiology researcher, describes the role of status as a core concern can help leaders avoid organizational practices that stir counterproductive threat responses among employees. For example, performance reviews encroach on status. Another status threat is offering feedback. It is usually a good way to sever relationships.[2]
Thank
Hearing “thank you” from my boss is the most frequent response from middle managers when asked for two words they most want to hear. Why? It means they value me. A survey from the American Psychological Association found that feeling valued at work links to better physical and mental health, as well as higher levels of engagement, satisfaction and motivation.
Thanking someone for coming to the interview even though it was mandatory lets them know you see them as a person. Thanking them throughout the interview and at the end helps to build trust and open communication.
Empathize
Empathic listening is not a natural skill to master. The mind holds prejudgments and misconceptions that can interfere with listening with an open mind. Listening with empathy, our perception shifts from our inner world into the place from which the other person is speaking. Empathetic listening is more difficult when the speaker is in pain, angry, or upset.
During a sensemaking session it is best to have a team of diverse people. However, their differences have the potential for threat responses. Trust cannot be assumed or mandated, nor can empathy or even goodwill be compelled. These qualities develop only when people’s brains start to recognize former strangers as friends. This requires time and repeated social interaction. You cannot throw a diverse group of people together without special preparation.
Notice
Notice your body’s reactions to pick-up on somatic sensations that indicate subtle shifts in your attentiveness. As we slip between these different fields of attentiveness, we transform our ability to hear, see and extrapolate. This skill is often called self-awareness.
Conclusion
Here are a few words of caution for the aspiring listener and sense-maker. We believe ourselves to be much better listeners than we are. According to Dunning and Kruger (1989), not only do we over estimate our abilities, but we also under estimate the power of our misapprehensions to create barriers to new learning. It is a constant challenge to question what we hold to be true when others present new evidence.
It helps to understand that our assumptions and need for psychological safety distort to an unknown degree what we hear and perceive. We block out information if it does not fit our needs and pre-judgments. When you are in a situation where everything you hear confirms what you already know, then you are listening judgmentally. This habit keeps us in old thinking that may no longer be true even if it feels right, known, acceptable, or easily verifiable. It may fulfill our quest to feel safe, but it doesn’t help us solve problems that we have never seen before or understand recurring phenomena that persist regardless of our efforts to fix it.
[1] Weick, K. (1995). Sensemaking in Organisations. London: Sage.
Weick, K., Sutcliffe, K. M., & Obstfeld, D. (2005). Organizing and the process of sensemaking. Organization Science, 16(4): 409–421.
[2] Rock, D. Managing with the brain in mind. (11/5/2021) https://www.strategy-business.com/article/09306
