事故调查的真正目的是司马?

I was listeningto a news report on the radio this morning about the pedestrian bridge collapsein Miami. At one point, they were interviewing Florida Governor RickScott.  Here is what he said:

“There willclearly be an investigation to find out exactly what happened and whythis happened…”

My ears perkedup, and I thought, “That sounds like a good start to a root causeinvestigation!”

And then hecontinued:

“… and wewill hold anybody accountable if anybody has done anything wrong,”

Bummer. His statement had started out so good, and then went directly to blame in thesame breath.  He had just arrived on the scene.  Before we had a goodfeel for what the actual circumstances were, we are assuming our correctiveactions are going to pinpoint blame and dish out the required discipline.

This is prettystandard for government and public figures, so I wasn’t too surprised. However, it got me thinking about our own investigations at ourcompanies.  Do we start out our investigations with the sameexpectations?  Do we begin with the good intentions of understanding whathappened and finding true root causes, but then have this expectation that weneed to find someone to blame?

We as companiesowe it to ourselves and our employees to do solid, unbiased incidentinvestigations.  Once we get to reliable root causes, our next step shouldbe to put fixes in place that answer the question, “How do we prevent theseroot causes from occurring in the future?  Will these corrective actionsbe effective in preventing the mistakes from happening again?”  In myexperience, firing the employee / supervisor / official in charge rarely leadsto changes that will prevent the tragedy from happening again.

Comments 1: After his second statement it will be hard to findthe root causes because all of them will hide the true information.

Comments 2:  That’s always the problemwhen we start blaming people and threatening discipline before we evenunderstand the root causes.