{"id":1057,"date":"2016-12-18T10:40:01","date_gmt":"2016-12-18T18:40:01","guid":{"rendered":"http:\/\/b-spoke.net\/?p=1057"},"modified":"2026-06-29T22:00:30","modified_gmt":"2026-06-29T22:00:30","slug":"good-investigators-dont-search-for-the-who","status":"publish","type":"post","link":"https:\/\/thirdactmedia.com\/b-spoke\/2016\/12\/18\/good-investigators-dont-search-for-the-who\/","title":{"rendered":"Good Investigators Don’t Search for the Who"},"content":{"rendered":"

Part One of Three<\/em><\/span><\/p>\n

A Four Minute Read<\/h6>\n

In her excellent book The Crash Detectives<\/em>, journalist Christine Negroni<\/a> surveys a century\u2019s worth of aviation disasters, and the investigations into their causes. One particularly compelling story is of a 2009 \"problems\"<\/a>
\nmedical evaluation; conditions were so bad that after four missed approaches into Melbourne, the ultimate solution was to put the plane down in the Pacific. It\u2019s a harrowing tale of too-few life jackets and a pilot who spent ninety minutes swimming around like a border collie to keep the passengers together before a fishing boat finally found them. Everyone survived.<\/p>\n

By almost any measure, Captain Dom James was a hero that night; to one man at the Australian Civil Aviation Safety Authority, he was a goat. CASA director of safety John McCormick told investigators that the evening\u2019s events were \u201centirely the fault of the captain.\u201d Subsequent investigations \u2013 including a particularly scathing television report<\/a> \u2013 harshly exposed that lie, claiming that McCormick \u201cattacked\u201d Captain James, calling his inquiry \u201cmanifestly unfair\u201d and accusing it of covering up key facts.<\/p>\n

http:\/\/mpegmedia.abc.net.au\/news\/fourcorners\/video\/fourcorners_12_10_0309_288p.mp4<\/a><\/video><\/div>\n

Source: Australian Broadcasting Company<\/a><\/em><\/p>\n

 <\/p>\n

This story resonates because it centers on a bias I\u2019ve confronted so many times as a manager and troubleshooter: When something goes wrong, the initial instinct is to focus on who<\/em> screwed up. Too many root cause analyses have spiraled into a \u201cwho do we fire\u201d exercise, where a \u201csuccessful\u201d resolution is indeed some poor sap\u2019s termination.<\/p>\n

To say this is human nature is beyond my expertise, but it is remarkably common. Gene Krantz and his colleagues \"hanks\"from the Apollo XIII mission are routinely cited as the gold standard in applying critical thinking during chaos; even so, in Ron Howard\u2019s film, Jim Lowell\u2019s first line of dialogue after the onboard explosion is, \u201cWhat did you do?\u201d Our nature to pursue a specific bad actor with a Javert-like mania, as CASA\u2019s McCormick did, is as harmful as it is natural.<\/p>\n

Why \u2018Harmful\u2019?<\/h4>\n

A full reckoning of that flight showed a number of factors that contributed to the crash. Captain James had insufficient tools to create and file his flight plan (which included the availability of accurate flying conditions); safety regulations excused the need for air ambulances to carry enough fuel to divert in case of inclement weather; he topped the tanks on the assumption he would be able to fly in airspace conducive to more conservative fuel consumption, but the aircraft lacked the necessary equipment to enter that corridor. Reminiscent of the Continental Connection 3407 crash in Buffalo, NY, earlier that year, crew scheduling rules led to significant pilot fatigue.<\/p>\n

Because of his preconception of the captain\u2019s guilt, McCormick omitted all of those details from the official investigation. \"javert\"In her book, Negroni quotes a 2007 study: \u201c\u2019The assignment of blame artificially and prematurely<\/u> restricts the investigation process\u2019 and can even stop the investigation in its tracks.\u201d This is confirmation bias, and it is an all-too frequent story: Once a team has locked onto a pet cause, the analysis becomes an exercise in collecting incriminating evidence, at the expense of finding alternate theories.<\/p>\n

Captain James is not blameless in this story; ultimately, he was responsible for putting that plane in the sky. The consequences to him of not<\/em> flying (fighting his bosses, mucking through red tape) were more exhausting then his perceived risk. And therein is the tale that my investigation teams have dealt with over the last two decades, whether we were trying to figure out how Eddie Vedder got lost to why 38 trailer loads of finished product were rejected by the retailer to whether or not that overheating on the reactor\u2019s rods was something to worry about.<\/p>\n

It\u2019s Not the Who<\/h4>\n

At their core, all of these inquries incorrectly focused on finding out who the guilty party was: Who<\/u><\/em> was the last \"the-who-doing-tommy\"person to see Eddie, who<\/u><\/em> ran the tests on the raw material, who<\/u><\/em> was supposed to call who in the control room. But the heart \u2013 the root cause \u2013 of almost every legitimate problem does not rest with bad employees, but with systems and leaders.<\/p>\n

Most managers scoff at that, and then outright laugh at this: Employees don\u2019t want to screw up. Almost no one gets up in the morning and thinks, \u201cToday\u2019s the day I get to act in total disregard for my coworkers, bosses, customers, and equipment!\u201d It all comes down to Binney\u2019s Second Law<\/a>: Everything is either a \u201cleadership problem\u201d or a \u201ctraining problem\u201d.<\/p>\n

If employees have never been trained in how to do something, or how to do it, it is tough to nail them for getting it wrong. Even then, research shows that lack of training is the cause of less than one-sixth of operational problems. The rest come from leadership issues:<\/p>\n