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Assign the investigation#

When your team or organization has had an incident it’s ideal to mobilize your investigation process as quickly as possible to extract as much learning as you can from this unplanned event.4

Investigations need to be assigned to someone in particular. Though they can be collaborative, it’s important that one person be responsible for moving the investigation forward. Assigning someone upfront also ensures that you’re picking someone who has the capacity to take on an investigation and is in a good position to do so.

First, assign an investigator who will own the responsibility for the investigation all the way through the process (from initial analysis through distribution of findings). While this step may seem straightforward, not everyone will be a good match for every investigation.

This person:#

Should... Shouldn't be...
Have a foundational level of knowledge of the components involved in the system Someone directly involved in the response and mitigation of the incident
Be trained on investigation techniques, interviewing, and facilitating post-incident learning reviews Untrained, inexperienced, or completely new to the organization
Be committed to establishing or reinforcing a post-incident process where participants feel safe In a position of authority over participants and interviewees
Be able to dedicate time and attention to driving the investigation through to completion

Why these things?#

Someone with a foundational level of knowledge will be able to understand the technical issues involved. That person also being trained in investigation techniques, including knowledge elicitation5 allows them to better surface information and ask better questions. Without someone who is committed to helping people feel safe, it will be difficult to get their perspective.

It’s not recommended that someone who was directly involved in the incident investigate it because that can unintentionally bias them. Being directly involved can also prevent an investigator from being seen as a neutral third party. Similarly, the facilitator shouldn’t be someone with authority over the interviewees in order to not create a fear of reprimand, concerns about looking unsure in front of management, or doubts around admitting to doing “the wrong thing,” all of which can limit the learning that takes place.

We understand that every organization is different, and they may not be able to find investigators who meet all these requirements (some companies may only have one team doing incident reviews, or a smaller startup may have everyone involved in every incident). If this applies to you, make sure to remind your team to take a third-party perspective.

Accepting an investigation#

If you’ve been asked to lead an investigation, awesome! We’re here for you. A few things to consider when accepting an investigation are:

Do you have the time to handle your colleagues’ potentially challenging experiences with care and attention#

A clumsily executed investigation can make things worse in terms of people’s difficult emotions in the aftermath of an incident. In order to determine if you have the bandwidth necessary, think of the length of the incident and the conversation surrounding it because you will need to become acquainted with the whole thing prior to starting the incident investigation.

It’s also important to consider the impact. Incidents with higher impact (e.g., it made the news, led to a large monetary loss) may be emotionally and politically charged, which can have an impact on participants and you as the investigator. It’s important that you’re able to be impartial and empathetic to the situation.

Can you meet the deadline being set, or are you able to manage your workload to finish the investigation in a timely manner?#

Some incidents will take a long time to give due diligence, you will have to balance thoroughness with prompt interviews (while the incident is fresh on people’s minds).