Reference Paper–When Things Go Wrong–Initial Responses

July 17, 2006



There is nothing so challenging as reacting to the occurrence of an incident that has the potential to result in significant negative consequences. These situations often announce themselves in a way that puts people off balance. The initial reports of the situation are sketchy, presumed accurate, and accompanied by scenarios of dire consequences if corrective action is not immediately taken. In the shadow of this chaotic background, an orderly guide is required for the first response.

In fact, these types of problems often do require a decision to be made and executed under severe time pressures. It is a highly leveraged time period since, if an appropriate response can be made, the issue is settled almost without notice. On the other hand, an inappropriate response can reverberate throughout the organization.

The correct decisions during the initial evaluation have the greatest leverage in bringing adverse situations under control. In the absence of an initial plan, there is a much greater possibility that the investigation will drift, inappropriate actions taken, and the problems will be compounded.

This section provides guidance for the initial actions to be taken when an incident occurs. Although such incidents may be referred to as “crises”, they are not true cataclysmic events. Time sensitive adverse situations can normally be expected to arise during the course of the project. However the event does put the project on a crossroad in that the outcome can range from full resolution to more severe problems. The objective of the framework outlined here is to increase the probability for a good outcome. The intent is to provide sufficient structure to establish an appropriate initial direction without rigid details. The techniques for technical resolution of the situation itself are addressed in other sections.

Examples of adverse events considered here:

Equipment malfunction

Schedule changes mandated by customers

Customer complaints

Change in management focus

Key Personnel Changes

Consequences of decision errors

Personal issues

These examples have common elements in that they are significant, but not life or safety issues. There is a short list of immediate concern that go beyond the typical events that comprise the majority of work situations. These events must be immediately escalated to trained personnel:

Safety issues

Personal injury

Property damage

Imminent danger of personal or property damage

The guide here also serves to provide a brake against the belief that the issues cannot be resolved correctly because actions have to be taken immediately. It is crucial to counteract the strong pressures to react to the situation even as the understanding of it changes on a moment-to-moment basis. If these pressures are not successfully neutralized, they increase in strength and can ultimately cause the troubleshooting activities to lose focus and essentially drift, compounding the issues and leading to a general deterioration of the situation. On the other hand, when the initial steps of the investigation are completed and priorities evaluated, the problem can be addressed with more confidence. The positive energy of confidence contributes further to maintain the problem resolution activity on track.

3 Anchoring Points

Three points are described that can be used as a foundation framework during the early stages of the investigative process.

1. Get a realistic view of the relation between time, risk, and consequences.

2. Identify the real driver.

3. Emphasize appropriate assistance.

Reference to these markers can provide sufficient grounding of the activities to develop and maintain the focus of the effort on the critical points. During the initial stages, it is difficult to resist the forces to act immediately in the direction most visible at the moment. The pressure to act is intensified by both the frustrations encountered in seeking accurate information and also by the psychological stress induced by the confusion. Reference to these 3 anchoring points are an effective way to keep the initial evaluation on track.

1. Develop a realistic view of the relation between time, risk, and consequences.

The first report of a time sensitive problem is usually only an indication of the actual situation. Obtaining a realistic view takes some effort, but plans and actions cannot be taken until the most accurate information that can be available is brought to the surface.


The initial reports tend to be biased toward overestimating severity. These initial reports also carry more psychological weight over time. An example of their psychological weight is that the first descriptions tend not to be discounted even as more accurate and relevant information becomes available.

As another perspective, it is noted that the bias to overestimate severity for incidents with time pressure does not apply to chronic problems. Chronic problems are generally reported with a more optimistic bias. In the chronic cases, there is an implied expectation that there is sufficient time to intervene and correct the issues before the negative consequences are fully manifested. This difference can be at least taken into consideration when information is evaluated.

Obtaining Available Information

The individuals who require the information and are responsible for corrective action must be the most organized and systematic. Eliciting the maximum quantity of available information is a skill activity of formulating and asking appropriate questions.

Internal Planning

The strong tendency to immediately begin asking questions of others involved in the incident is not the most effective approach. Only several minutes are required to explicitly formulate an overall strategy to obtain information. Using a strategy can make a significant improvement in the quality of information obtained. Many people can formulate the strategy as an intuitive skill. However, it can be a learned skill and an approach is outlined below:

The driving internal question for yourself is:

What I really need to know is _______?

This formulation consistently applied can guide the data gathering to the most effective level.

The answers to the above question serve to provide a foundation upon which to evaluate the information.

Who may have this information?

What can be done with this information?

This internal planning exercise, completed in several minutes, is a reference to ensure that the external investigation remains on track.

External Questions

After the outline of an internal information strategy has been developed, the activity of gathering the available information can begin. The objective is to ensure that information is brought to the surface for evaluation. This surfacing of information is a skill driven activity. The probes and questions may be seeking specific facts or explore the possibilities. The section: Formulating Appropriate Questions reviews the different types of questions that can be helpful in obtaining information.


Skilled: “What was the first indication that ….. .. . .. happened?”

There is specificity, but is still open-ended with opportunities for follow-up.

Unskilled: “What do you know about . . . ?”

Trolling for information with this type of question will lead to responses with omissions and exclusions.

Due to the ambiguity of the situation, and normal discrepancies in observation and interpretation, the information and data will become available in an unfiltered way. While all the information must be gathered objectively, the raw information can be roughly sorted into several heaps:



Significance initially unclear

Not Available

The sorting process itself is both informal and fluid. The significance of any piece of information can change as a more complete picture emerges. Consequently, it is a common occurrence to upgrade or downgrade information in much the way that stocks trade up or down based on financial news. The sorting process itself adds value since, as a background activity, it continually re-enforces the focus on the information that is most relevant to the priorities.

The process also serves as an internal reminder that, at the early stage of the investigation, the analysis process must be open and agile rather than concentrate on fitting the facts into a preconceived framework. As described in the next section, the information is first used to understand the priorities in terms of time and risk. After time and risk are assessed, the details of the problem itself are addressed.


2. Identify the critical priorities in terms of time and consequences

The first use of the available data is to qualitatively determine a realistic relationship between time and potential downside consequences. The risk management techniques (Section xx) can be used with the available facts to develop the risk scenarios. This exercise is informal and rapid. The objective is to use a process to identify the boundaries of downside consequences as a function of time. The results of the exercise allows everyone in the organization to understand the actual dimensions of the incident. A succinct statement of the actual problem, based on the best available information, can displace the initial, more diffuse initial reports. This problem statement, more than anything, can settle the situation down in a direct and rapid way. It is a step required before the underlying problem can be rationally addressed. Again it is stressed, that it is the exercise as much as the result that has value. The downside risk is determined by one or several key individuals in an informal manner, and does not require an elaborate procedure.

Note that there is a significant difference between using the available information to define the parameters of the problem and using the information to solve the problem directly. The intent at this stage is to use the information to define the acceptable boundaries for time and risk. This objective can be met without an in depth probe. This is an important distinction since initially available information is usually not sufficient to actually resolve the problem. A more detailed technical analysis is usually needed to actually determine the best course of action to resolve the consequences of the incident.

In some cases, the pressure source is obvious and the time frame and first course of action are clear. An example, are hazards that require immediate attention. However as noted earlier, the majority of time pressure decisions fall into a more ambiguous category

Examples of driving priorities may include:

Revenue loss

Schedule Commitments

Production Downtime


Organization Goals

Personal Goals

Viewed in terms of the possibilities of the different priorities, it is clear that the critical ones must be identified early in the evaluation. Failure to make this identification can lead to addressing a secondary issue with an inefficient and costly use of time and resources.

More specifically, an awareness of the options also serves as a break to the direct implementation of the first underdeveloped ideas and the beginning of the compound error scenario.

Priority of Action

The key question to reframe and focus the activity:

“What do we want to happen?

The follow-up question addresses the effort:

“Are the current activities consistent with the goals ?”

or rephrased as:

“Is priority where the effort is directed?”

If the desired result is known and kept in the forefront of attention, information, advice, and activities can be evaluated against a reference. Although this direct focus appears to be a straightforward approach, in the confusion induced by the incident, it is often difficult to maintain a clear relation between the goals and the activities. There are many diversions. Experience has demonstrated that, without guidance, effort will go to the easiest task that may give the appearance of progress or follow the most vociferous opinion. These two questions serve as landmarks to gauge the priority of the activities.

Examples of diversions that can frequently arise:

Minor considerations get disproportionate attention.

Easiest task that may give the appearance of progress.

Vociferous opinion demands more attention.

Repetitive communication

(Communication is an important activity, but it is not the goal.)

Reopening issues with no additional information.

3. Emphasize Appropriate Assistance

There is one straightforward guide:

Find and use the best people who can contribute to understanding the situation.

This guide is not as easy to follow as it appears. Everyone wants to help. Not everyone can. This distinction between appropriate and inappropriate assistance must be kept in mind during the activities seeking to understand the information and devise a path forward. The most useful people to consult to get the process moving in the right direction should be identified explicitly. Generally, one key to recognizing the situation is the level of accountability, either for the cause of the incident or for its resolution

There is difficulty in maintaining the distinction of inappropriate assistance. There are cadres of people who are eager to contribute, but do not add to the resolution process. For example, people who happen to be in the vicinity seem to be especially influential regardless of their expertise or accountability

On the other hand, there are ubiquitous anecdotal examples of the winning direction being contributed by someone outside of the project. There is always the possibility of overlooking a relevant contribution from an unlikely source. This possibility is mitigated by listening to these contributions, but adjusting the weight based on the source. In this way, all contributions are gathered, but action and direction are not buffeted by low credibility information.

The focus has to be on the first line of information holders and advisors. This approach increases the likelihood of a successful resolution.

Summary Comments:

  • Unplanned incidents will occasionally occur in all projects
  • These situations are accompanied by significant time pressures that can impede judgment
  • Take the short time required to understand the problem before moving toward a solution. It is more efficient to initially think than act.
  • Use three anchoring points to guide this evaluation.

1. Get a realistic view of the relation between time, risk, and consequences.

2. Identify the real driver.

3. Emphasize appropriate assistance.

  • The evaluation is rapid and informal
  • After the initial evaluation, address the resolution of the major issues

The key point is to take the short time required to understand the problem before moving toward a resolution.