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  • John Kingston

Coming to terms... of reference

How do you get value from internal investigation? Senior managers seldom investigate accidents personally. But, left to their own devices, more-junior managers tend to be conservative about the questions they set out to answer. Instead of learning, which means facing-up to the need to improve, their tacit aim may be to show the rightness of business as usual. As noted in other posts, it’s easy to fool oneself about the causes and to solve the wrong problem. To add to the mix, at the start of a safety investigation, it’s normal not to know precisely the right questions to ask. The way out of the maze is found by managing the terms of reference. One of the rare sources of guidance about this is a Home Office review into an internal police investigation called ‘Operation Lancet’. Although not about safety investigation, the Lancet review report gives relevant advice. Terms of reference should be: (1) clear, unambiguous, tightly drawn and without open ended phrases; (2) dynamic, to allow them to be revised in the light of new information; and, (3) developed multilaterally. I set out the reasons behind these principles in a paper published in July, 2021. A multilateral approach means top management must share power with stakeholders. The coupling between dynamic review and tight phrasing also implies partnership. So, make no mistake, your colleagues may well see these principles as a challenge, but it’s one that everyone can rise to with good leadership. After all, whose safety is it, anyway?


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