We have long struggled with trying to capture the facts associated with an accident in order to prevent the next one. This has been largely effective when applied to machines. In mechanical systems things are measurable, observable and more objective.
The information we get from people is always subjective. There are always issues of memory, shame, fear and politics that influence the ever-changing stories we tell. If you think about it, you have probably altered a story to make a point or to protect something that you value. Stories are altered both consciously and unconsciously – we are influenced by a myriad of things including: what we have seen in the past, other stories, and what we think the listener may want to know or hear.
Memory is truly malleable. People think in ‘story’ and these stories are not accurate recordings of an event, rather they are linked memories that help us make sense of events. Our experiences set us up to make sense of a situation, for ourselves. Daniel Kahneman tells us that we actually approach the present by already thinking of the anticipated memory we want to keep. This anticipation is based on our experiences. We then edit, reconstruct, change or alter the memories and stories naturally – and it does not stop there. The future literally changes how we remember the past. Everything is influenced by preconceptions, stereotypes, and biases.
Most formal schools of accident investigation openly admit that witness statements are notoriously inaccurate. Yet, most investigative processes use participant’s memories to build a “factual” narrative. Once written down, the nature of the process changes memory into fact and the credibility of the process that created the narrative can confer even more power to a story. Much like propaganda, these stories can be intentionally used as a trigger to learning or behavioral change. History is replete with stories that are designed to create such changes.
However, in today’s society, “Fact checking” by even casual readers is quite normal. A plausible story may elicit a Google search on a personal device that could challenge the contention of the organizationally approved story. More importantly, the community of practitioners, familiar with the work environment, often challenges the accuracy of the story and the conclusions. A story may not be enough to change old behaviors or to create new ones.
This realization has driven an unexpected shift to a different kind of story. The new story focuses less on the narrative and actions or decisions of people, and more on the conditions that influenced those actions or decisions. The practice that emerged is designed to map the network of influences, which has two main purposes – First, to increase field operator awareness of the influencing conditions and how they can recognize changing conditions. Second, identification of conditions that make the system more brittle, which forms a starting point for leadership actions designed to improve the likelihood of workforce success.
 The practice is called a “Learning Review,” which is currently being used by the US Forest Service and several high-risk industries throughout the world.
Editor’s note – This will be the first in a series of posts from Ivan on his developing better learning and investigation practices. Keep an eye out for more from Ivan on this topic in the future!