Destructive Thinking Patterns: Who Hides the Truth During Investigations

Thinking Traps in Incident Investigations

Internal incident investigations are an integral part of developing a safety culture at any enterprise. However, a situation often arises where the root cause is found, corrective actions are implemented, yet incidents recur. Roman Portnyagin, Head of the Investigation Process Development Department at Nornickel, examines a hidden problem: the destructive thinking patterns of the experts conducting the investigations. Using an example, the speaker shows how personal cognitive biases lead the commission to a dead end, preventing them from identifying the true causes.

The Perfect Movie Effect and Counterfactual Thinking

The first trap is counterfactual thinking. Experts often build a timeline of events by comparing a real worker with a fictional ideal character who is always well-rested, knows all the instructions, and makes no mistakes. Reasoning from a "safe future," the commission concludes: the worker forgot to press a button or violated a clause in the instructions. This approach does not explain why the employee acted that way, but merely states the fact of deviation from the ideal.

Semantic Dead End and Linguistic Traps

The second problem is the use of evaluative words masquerading as root causes. The presentation details an example with the phrasing "insufficient control" or "lack of knowledge." The speaker emphasizes that words meaning "insufficient" are not root causes, but intellectual capitulation. A tautology arises: the accident occurred due to insufficient control, and the control is deemed insufficient because the accident occurred. Such formulations do not fix the system; they merely attach labels, like wallpaper hiding a crack in the wall.

The Mechanistic Illusion: Human as a System Adapter

The third trap is perceiving a person as a mechanism that can be "fixed." If a pump breaks down, we look for a technical fault. Transferring this logic to people, we ignore the context: fatigue, family problems, working conditions. The speaker notes that in new approaches to safety culture, a person is viewed not as a violator, but as an adapter of an imperfect system. People deviate from instructions not for the sake of sabotage, but to fulfill the plan in conditions where the system does not work perfectly. The task of the investigation is to understand the worker's logic at the moment of decision-making, rather than simply recording a violation.

Balance in Implementing Corrective Actions

Even if the root causes are identified correctly, the problem of implementing large-scale and expensive measures arises. Department heads often resist their implementation due to a lack of resources. The solution lies in finding a balance and applying the principle of rational sufficiency. If it is impossible to immediately invest large sums in modernization, it is necessary to take preventive measures here and now — for example, strengthen control or add a staff unit, while planning global changes in the next year's budget.

What you will learn from this webinar:

• Why do identified root causes often fail to prevent the recurrence of incidents?
• How to avoid counterfactual thinking when building a timeline of events?
• Why do phrases like "insufficient control" lead an investigation to a dead end?
• How to change the approach to investigation by viewing a person as a system adapter rather than a mechanism?
• How to overcome the resistance of managers when implementing costly corrective actions?