The Detective’s Trap
You start an investigation by asking "Who did this?" Why is this a trap?
What creates a blame culture where people hide the "Background" to protect themselves
Focusing only on the injury only makes us blind to what else is happening in the background (the dishes breaking).
Why was focusing only on injury, like in the shell game (with the "Kiss" (the cut)) will not prevent the incident to reoccur?
Correct this: "The kitchen floor was a total mess."
Correction: "There were broken ceramic plates covering a 3 meter - 15 feet area behind the prep station."
An over stacked bin caused the dishes to fall in the fruit-cutting case.
What is a "Physical/Resource" system failure in the fruit-cutting case?
You are so focused on Jordan's cut finger that you don't look at what happened behind her.
What is Inattentional Blindness (or the Selective Attention Trap)
When investigating, the kitchen was short-staffed and people were rushing. People were taking shortcuts this is normal, we want no delays.
How does a "No Delay" Bias affect our investigation?
Correct this: "The dishwasher never secures the carts.
Correction: "The dishwasher failed to apply the breaks on the carts during his shift on Feb 15th and Feb 18th
In the case of Joe, his statement did not relate to the manner he communicated with John, the Human to Human interactions or People factor.
How the Human to Human interactions (People, contributing factor) not covered in Joe's statement?
You arrive at the scene 2 hours late, the broken dishes were swept up, so you can no longer see why they fell.
What is the risk regarding the "broken dishes if the scene is not freeze quickly"?
A simple story is given: "She just slipped."
Simple stories often hide complex system failures (like why the dishes fell)
Why should you stay skeptical as an investigator?
Correct this: "The noise was unbearable and dangerous."
Correction: "The sound of breaking dishes measured 90 decibels and triggered a startle response."
By fixing the "Swamp" to ensure effective training, adequate Design/Resources, Proper Defenses, and Aligned Goals you reduce the holes in the Swiss Cheese Safety System model.
How do you "Shrink/Reduce the Holes" in the system?
You think Jordan is "clumsy" because she’s been injured before, so you look for evidence to prove it.
What is a Confirmation Bias?
People are rushing to hit KPIs. People are recognized as good firefighters (No Delay vs. Safety).
What "Invisible System" is influencing them?
Correct this: "Jordan obviously wasn't paying attention to her surrounding, when she cut herself."
Correction: "Jordan responded to an external acoustic trigger (breaking dishes) resulting in a 1cm laceration on the left index finger.
Having a job risk analysis validated and reviewed when change are made to workstation, workplace contributes to reducing the hazards. This confirms if the different Swiss Cheese holes in a Slice are misaligned with other holes in the other slices.
How do you ensure "Cheese Holes" don't align?
You recommend "Retraining Jordan on knives" but don't look at how dishes are moved.
Why it doesn't fix the issue related to the next noise that will cause the next jerk?
Not investigating why dishes are being moved in small bins over stacked. It’s an oversight of an Equipment/Procedural System failure that creates the "Bang" trigger like missing the duck in the shell game.
How can focusing one one point only leads us to the wrong conclusion, like missing contributing factors or root cause?
Write a 3-Step Sentence for Jordan's injury (Subject, Observation, Standard).
Correction: "Employee Jordan (Subject) jerked her knife in response to a noise (Observation) which is an Environmental Hazard under the Risk Analysis (Standard)."
When colleagues start over-stacking dish in bins to save time, or when yelling is tolerated and it becomes "normal" until they finally tip over or violence takes place.
What is "Practical Drift" in the Swiss Cheese slice?