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The views expressed in this presentation are the views of the author/s and do not necessarily reflect the views or policies of the Asian
Development Bank, or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included
in this presentation and accepts no responsibility for any consequence of their use. The countries listed in this presentation do not imply any
view on ADB's part as to sovereignty or independent status or necessarily conform to ADB's terminology.
A Guide to Effective Incident
Investigation
Olivier Serrat
2013
Tales of the Unexpected
One might think there are no
answers to the following
questions:
• How fast can you think on
your feet?
• How do you react in the
face of the unexpected?
How can you prepare if you
cannot predict?
And yet, there are: evidently,
some behaviors contribute to
the success or failure of
individuals—and
organizations—in specific
situations.
If history repeats itself, and the unexpected always happens,
how incapable must Man be of learning from experience.—
George Bernard Shaw
Tales of the Unexpected
Responses to the
unforeseen lie in
identifying before
the fact events or
circumstances, or
series of them, that
are outside the
range of ordinary
human
experiences.
Critical incidents
can be harvested to
provide a rich,
personal
perspective of life
that facilitates
understanding of
the issues and
obstacles people
face every now and
then.
Critical incidents
illuminate avenues
for improvement
(or replication if
outcomes are
effective)—avenues
that may not be
apparent through
purely quantitative
methods of data
collection.
Of Critical Incidents
A critical incident need not be spectacular: it suffices that it
should hold significance. As such, at the individual level, it can be
events or circumstances that made one stop and think, perhaps
revisit one's assumptions, or impacted one's personal and
professional learning. At the collective level, it can be a systemic
problem from organizational maladaptation, or an issue arising
from differences among stakeholders.
In short, an incident may be defined as critical when the
action(s) taken contributed to an effective or an ineffective
outcome. At heart, all incidents pertain to matters such as
culture, knowledge, competence, relationships, beliefs,
emotions, communication, or treatment.
The Critical Incident Technique
John Flanagan described the Critical Incident technique he
pioneered as "a set of procedures for collecting direct
observations of human behavior in such a way as to facilitate
their potential usefulness in solving practical problems and
developing broad psychological principles."
The Critical Incident technique seeks, largely through qualitative
processes of exploration and investigation, to identify actions
associated with effective or acceptable performance in defined
situations.
The analysis of a critical incident describes the setting in which
an incident occurred, the behavior (including the attitudes,
emotions, skills, knowledge, and resources) of the people
involved, and the outcome or result of the behavior.
The Critical Incident Technique
To kick off a Critical Incident technique intervention, it is
essential to agree on whether the issue meets
established critical incident criteria and then prepare a
clear, concise statement of the purpose of the
intervention.
If the issue meets the criteria can the agency secure
stakeholder support and capacities for an intervention?
Next, one must understand what core questions need to
be addressed, especially as this helps prioritize the
intervention and its expected impact against other
priorities.
The Critical Incident Technique
• What were the events or circumstances
that led to the critical incident?
• What were the behaviors of the agents
that made these (events or
circumstances) a critical incident?
• What were the outcomes of the critical
incident?
• What are the possible future outcomes if
behaviors remain unchanged? What are
the possible future outcomes if behaviors
change based on lessons learned?
Specifically, the
Critical Incident
technique asks:
The Critical Incident Technique,
Cont.
Does the issue meet
the critical incident
criteria? Is it a
critical incident?
Can you secure
stakeholder support
and capacities for
an intervention?
Decide on another
technique to
address the issue.
Decide on another
technique to
address the issue.
Identify the core
questions to be
answered.
NO
NO
YES
YES
The Critical Incident Technique
Hold the
intervention, collect
the data needed,
and analyze and
interpret it.
Design a strategy
and plan to solve
the problem with
inputs from relevant
parties.
Present the final
strategy and plan to
the relevant parties
for agreement.
Agree with the
relevant parties on
the review process
and timeframe
whereby progress
will be evaluated.
Make necessary
changes based on
the lessons learned.
Evaluate the
intervention with
inputs from the
relevant parties.
Implement,
monitor, report on,
and adjust the
intervention
strategy and plan.
Decide on the
investigative
method and
population for the
intervention.
Continued from
above
Source: Adapted from
Paul Davis. 2006. Critical
Incident Technique: A
Learning Intervention for
Organizational Problem
Solving. Development
and Learning in
Organizations. Vol. 20,
No. 2, pp. 13–16.
Pros and Cons of the Critical
Incident Technique
Some
advantages
of the Critical
Incident
technique are
that:
• It helps identify and analyze rare events
or circumstances that might not be
picked up by methods of investigation
dealing with everyday episodes. Its focus
on critical issues can bring major benefits.
• It maximizes the positive and minimizes
the negative attributes of anecdotes,
turning complex experiences into rich
data and information.
• It provides dramatic demonstrations of
the impact of behavior, whose cause and
severity may not have been known.
Pros and Cons of the Critical
Incident Technique
Other
advantages
are that:
• Critical incidents help gauge abstract
constructs such as motivation through their
demonstration in reported behavior.
• Critical incidents provide in-depth
information at a much lower cost and with
much greater ease than observation.
Some
limitations
of the
Critical
Incident
technique
are that:
• Critical incidents cast a personal
perspective on organizational issues.
(Reports of behavior are filtered through
the lens of individual perceptions, memory,
honesty, and bias.) Therefore, the Critical
Incident technique may need to be
combined with other methods of data
collection, analysis, and interpretation.
Pros and Cons of the Critical
Incident Technique
Other
limitations
of the
Critical
Incident
technique
are that:
• It cannot be assumed that people can and will
provide incidents that are critical to success in
their particular jobs—hence the need to
select critical incidents carefully—nor that
qualitative analysis alone is enough to clearly
identify the aptitudes, proficiencies, and
temperaments underlying success or failure.
• Some applications of the Critical Incident
technique take time: investigation of data and
information can be laborious.
• It may hard to entice people to share critical
incidents if the investigative approach
requires them to write their own stories.
Further Reading
• ADB. 2008. Conducting After-Action Reviews and Retrospects.
Manila. www.adb.org/publications/conducting-after-action-
reviews
• ——. 2008. Storytelling. Manila.
www.adb.org/publications/storytelling
• ——. 2008. Action Learning. Manila.
www.adb.org/publications/action-learning
• ——. 2009. The Five Whys Technique. Manila.
www.adb.org/publications/the-five-whys-technique
• ——. 2010. The Critical Incident Technique. Manila.
www.adb.org/publications/critical-incident-technique
Videos
• ADB. 2012. The Critical Incident Technique. Manila.
vimeo.com/67185516
• ——. 2012. The Five Whys Technique. Manila.
vimeo.com/67185517
• ——. 2012. The Reframing Matrix. Manila.
vimeo.com/67186254
Quick Response Codes
@ADB
@ADB Sustainable
Development Timeline
@Academia.edu
@LinkedIn
@ResearchGate
@Scholar
@SlideShare
@Twitter

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A Guide to Effective Incident Investigation

  • 1. The views expressed in this presentation are the views of the author/s and do not necessarily reflect the views or policies of the Asian Development Bank, or its Board of Governors, or the governments they represent. ADB does not guarantee the accuracy of the data included in this presentation and accepts no responsibility for any consequence of their use. The countries listed in this presentation do not imply any view on ADB's part as to sovereignty or independent status or necessarily conform to ADB's terminology. A Guide to Effective Incident Investigation Olivier Serrat 2013
  • 2. Tales of the Unexpected One might think there are no answers to the following questions: • How fast can you think on your feet? • How do you react in the face of the unexpected? How can you prepare if you cannot predict? And yet, there are: evidently, some behaviors contribute to the success or failure of individuals—and organizations—in specific situations. If history repeats itself, and the unexpected always happens, how incapable must Man be of learning from experience.— George Bernard Shaw
  • 3. Tales of the Unexpected Responses to the unforeseen lie in identifying before the fact events or circumstances, or series of them, that are outside the range of ordinary human experiences. Critical incidents can be harvested to provide a rich, personal perspective of life that facilitates understanding of the issues and obstacles people face every now and then. Critical incidents illuminate avenues for improvement (or replication if outcomes are effective)—avenues that may not be apparent through purely quantitative methods of data collection.
  • 4. Of Critical Incidents A critical incident need not be spectacular: it suffices that it should hold significance. As such, at the individual level, it can be events or circumstances that made one stop and think, perhaps revisit one's assumptions, or impacted one's personal and professional learning. At the collective level, it can be a systemic problem from organizational maladaptation, or an issue arising from differences among stakeholders. In short, an incident may be defined as critical when the action(s) taken contributed to an effective or an ineffective outcome. At heart, all incidents pertain to matters such as culture, knowledge, competence, relationships, beliefs, emotions, communication, or treatment.
  • 5. The Critical Incident Technique John Flanagan described the Critical Incident technique he pioneered as "a set of procedures for collecting direct observations of human behavior in such a way as to facilitate their potential usefulness in solving practical problems and developing broad psychological principles." The Critical Incident technique seeks, largely through qualitative processes of exploration and investigation, to identify actions associated with effective or acceptable performance in defined situations. The analysis of a critical incident describes the setting in which an incident occurred, the behavior (including the attitudes, emotions, skills, knowledge, and resources) of the people involved, and the outcome or result of the behavior.
  • 6. The Critical Incident Technique To kick off a Critical Incident technique intervention, it is essential to agree on whether the issue meets established critical incident criteria and then prepare a clear, concise statement of the purpose of the intervention. If the issue meets the criteria can the agency secure stakeholder support and capacities for an intervention? Next, one must understand what core questions need to be addressed, especially as this helps prioritize the intervention and its expected impact against other priorities.
  • 7. The Critical Incident Technique • What were the events or circumstances that led to the critical incident? • What were the behaviors of the agents that made these (events or circumstances) a critical incident? • What were the outcomes of the critical incident? • What are the possible future outcomes if behaviors remain unchanged? What are the possible future outcomes if behaviors change based on lessons learned? Specifically, the Critical Incident technique asks:
  • 8. The Critical Incident Technique, Cont. Does the issue meet the critical incident criteria? Is it a critical incident? Can you secure stakeholder support and capacities for an intervention? Decide on another technique to address the issue. Decide on another technique to address the issue. Identify the core questions to be answered. NO NO YES YES
  • 9. The Critical Incident Technique Hold the intervention, collect the data needed, and analyze and interpret it. Design a strategy and plan to solve the problem with inputs from relevant parties. Present the final strategy and plan to the relevant parties for agreement. Agree with the relevant parties on the review process and timeframe whereby progress will be evaluated. Make necessary changes based on the lessons learned. Evaluate the intervention with inputs from the relevant parties. Implement, monitor, report on, and adjust the intervention strategy and plan. Decide on the investigative method and population for the intervention. Continued from above Source: Adapted from Paul Davis. 2006. Critical Incident Technique: A Learning Intervention for Organizational Problem Solving. Development and Learning in Organizations. Vol. 20, No. 2, pp. 13–16.
  • 10. Pros and Cons of the Critical Incident Technique Some advantages of the Critical Incident technique are that: • It helps identify and analyze rare events or circumstances that might not be picked up by methods of investigation dealing with everyday episodes. Its focus on critical issues can bring major benefits. • It maximizes the positive and minimizes the negative attributes of anecdotes, turning complex experiences into rich data and information. • It provides dramatic demonstrations of the impact of behavior, whose cause and severity may not have been known.
  • 11. Pros and Cons of the Critical Incident Technique Other advantages are that: • Critical incidents help gauge abstract constructs such as motivation through their demonstration in reported behavior. • Critical incidents provide in-depth information at a much lower cost and with much greater ease than observation. Some limitations of the Critical Incident technique are that: • Critical incidents cast a personal perspective on organizational issues. (Reports of behavior are filtered through the lens of individual perceptions, memory, honesty, and bias.) Therefore, the Critical Incident technique may need to be combined with other methods of data collection, analysis, and interpretation.
  • 12. Pros and Cons of the Critical Incident Technique Other limitations of the Critical Incident technique are that: • It cannot be assumed that people can and will provide incidents that are critical to success in their particular jobs—hence the need to select critical incidents carefully—nor that qualitative analysis alone is enough to clearly identify the aptitudes, proficiencies, and temperaments underlying success or failure. • Some applications of the Critical Incident technique take time: investigation of data and information can be laborious. • It may hard to entice people to share critical incidents if the investigative approach requires them to write their own stories.
  • 13. Further Reading • ADB. 2008. Conducting After-Action Reviews and Retrospects. Manila. www.adb.org/publications/conducting-after-action- reviews • ——. 2008. Storytelling. Manila. www.adb.org/publications/storytelling • ——. 2008. Action Learning. Manila. www.adb.org/publications/action-learning • ——. 2009. The Five Whys Technique. Manila. www.adb.org/publications/the-five-whys-technique • ——. 2010. The Critical Incident Technique. Manila. www.adb.org/publications/critical-incident-technique
  • 14. Videos • ADB. 2012. The Critical Incident Technique. Manila. vimeo.com/67185516 • ——. 2012. The Five Whys Technique. Manila. vimeo.com/67185517 • ——. 2012. The Reframing Matrix. Manila. vimeo.com/67186254
  • 15. Quick Response Codes @ADB @ADB Sustainable Development Timeline @Academia.edu @LinkedIn @ResearchGate @Scholar @SlideShare @Twitter