Home Grown—What RCA Investigations should we lead?

Chris Eckert, President

“Should I have one of my people lead this investigation, or should I farm it out to a 3rd party?”

The answer depends on a few things including concerns about liability, desired turnaround time, availability of skilled, in-house facilitators, internal politics, the need for impartiality and budget.

When investigations are completed by your internal personnel: 1) There is a higher degree of ownership of solutions which improves implementation, 2) The facilitator’s skills improve making them even more effective on future RCA’s, 3) It will prevent lower level problems from growing into catastrophic events and 4) It eliminates the external spend associated with a 3rd party investigator.    But, sometimes the wolf is at the door, and when this happens you need the assurance that the problem is going to be handled quickly and efficiently and bringing in outside facilitators/investigators is the best way to guarantee that result.

So, what should you do?  Following are considerations to help you decide whether an internal or external investigator is best:
  • Is there a potential for litigation?  Are there concerns about discoverability?  If so, bringing in a 3rd party facilitator can be a smart move.  If the situation could result in a lawsuit against your company, now would be a good time for your internal counsel to retain an external law firm who can secure the 3rd party investigator.  The results of the investigation, even when your internal employees contribute and are members of the investigative team, will not be discoverable (Note: This holds for the US, but it may not be the case in all countries).  Thus, the team is free to explore all aspects of the event without fear of disclosing information that could later be used against the company. The investigation can be thorough and the team will not feel pressure to suppress information.  Effective solutions can be identified and deployed.
  • Need your report in a hurry?  This is becoming the deciding factor for many organizations.  When internal facilitators are used, their primary job duties can prevent sustained focus on the RCA.  As such, development of the final report (usually the most dreaded part of the entire RCA) gets put off.  Further, if internal facilitators do not routinely lead significant events, building the report consumes more time because they aren’t sure what the managers want, or need.  For most mid-size and even some larger events, unless additional follow-on testing or significant data gathering is needed, a 3rd party firm can turn around the final report within 1-2 weeks.  Because a 3rd party investigator knows what should be in the report and what leadership needs, reports are efficiently produced with very short edit cycles.
  • With fewer resources and subject matter experts in most companies, there are fewer people prepared to handle facilitation of significant incidents.  This has resulted in fewer RCA’s being performed allowing smaller and mid-size problems to evolve into significant events.  We have seen the losses associated with the typical event increase 10 fold in the last 5 years.  As much as I’d like to believe that the overall number of incidents has been decreasing, with just a few larger incidents continuing to occur, I know otherwise.  Unchecked, all major catastrophes can be traced back to a series of minor problems (causes) that were ignored or unaddressed.  Usually these causes are ignored for months and years.  All major events all preventable, but this can only happen when someone focuses on the elimination of the problem when it is still manageable (These are the situations for internal facilitators to apply RCA!).  
  • When two or more departments/organizations are involved in a dispute, impartiality of the investigation is paramount.  If an internal consultant (with facilitation experience and no stake in the outcome) is available to facilitate the internal disputes, that is usually very effective.  If the problem is too large, or in cases when the dispute involves a supplier or customer, you would be well served to bring in an external investigator.  3rd parties can ask the tough (and ‘stupid’) questions that often go unasked when an internal investigator feels pressure from a manager who would not look favorably on specific cause paths being included in the analysis.  “You never know, someday I may have to work for that manager--I better not go down those paths just to be on the safe side”.  Individual survival will trump solving an organizational problem almost every time. 
  • Is there concern over external spending?  Bringing in a 3rd party investigator can be a great solution, but it comes at a price.   In all but the simplest incidents, you should plan on $10,000 for an investigation that lasts 2 days.  While this seems like a lot, this will get you two highly productive days on site, a polished and professional final report and it includes the travel expenses of someone who knows how to run an investigation which makes efficient use of team member time.  Because the typical losses involved with incidents where 3rd party investigators are utilized starts in the millions of dollars, the investment you make in bringing someone ready to hit the ground will cost you a fraction of a percent of the total incident cost.    Even in cases where you ask the 3rd party firm to supply the subject matter expertise (such as metallurgists, lab testing, etc)  as part of their overall deliverables, normally, the total expenditure will still be less than 1/2% (<0.005) of the incident cost.

Of course, despite my best intentions, this may sound like a sales pitch for 3rd party investigations.  I will leave that for you to decide.  We have a passion for RCA and incident investigations and we are always happy to help our clients regardless of the situation.  However, given a choice, we prefer to install skills proactively by deploying the necessary training and program to create internal investigative capability.  Organizations that equip their personnel with the knowledge, skills and tools they need to investigate their own problems typically avoid situations where things blow up and require outside investigative assistance.  

Reacting to problems always costs more.  But, if you are in the middle of a major event wondering which direction to turn, bringing in an outside lead investigator will normally be your best move.  However, even if this is the case, don’t allow yourself to get caught in a reactive trap; once the 3rd party investigator wraps up their work, you still need to build and maintain internal RCA facilitation capabilities to avoid getting caught in a repeat situation (with the same or potentially worse catastrophic consequences).   

Today, many organizations are utilizing a combined strategy—for smaller to mid-size events, they utilize internal RCA facilitators.  For major events, as defined by their threshold criterial or RCA policy, they utilize external investigators.  The end result is program that has the best of both worlds; internally facilitate RCA that attacks most problems before they grow coupled with the quality and efficiency brought by an external investigator when the occasional major event occurs.
Still not sure what makes the most sense for you?  Contact us and we can talk through the specifics of your situation to find a solution that meets your needs.