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Incident and Accident Investigation

An investigation must clearly define what happened, what was supposed to happen, and identify why there was a difference. Anything less produces a report that assigns blame without changing the conditions that allowed the event. I conduct independent incident and accident investigations that identify root and contributing causes and recommend controls that prevent recurrence.

What an investigation has to establish

Three things, in order: what happened, what was supposed to happen, and why there was a difference. That third question is where most investigations stop short. Establishing that a procedure was not followed is a finding, not a cause. The useful question is why the procedure was not followed, and whether it could have been.

The four lenses

Every investigation examines the event through four lenses:

  • The event itself. The sequence, the conditions, the people involved, the equipment.
  • The organization's systems, processes and procedures. What the documented expectation was, whether it was workable, and whether the resources it assumed were actually available.
  • Regulatory and industry standards. What the applicable regulations and standards required.
  • Industry best practice. What a well-run operation would reasonably have had in place.

On blame

Employees remain responsible for their actions. But they do not necessarily have control over their workspace or the task. Typically an investigation reveals that the people involved did not intend the outcome and believed they were doing everything right.

A thorough investigation identifies the conditions that enabled the event. That distinction matters operationally, not just ethically: an investigation that terminates at "the worker made a mistake" leaves every one of those conditions in place for the next person. I have written about the reporting culture this depends on in Safety Culture or Organizational Culture?

It also matters to distinguish a system failure from a genuine shortcut. Where an employee wanted to do the job correctly but the tool was unserviceable, the procedure vague or the parts unavailable, that is an organizational risk that management failed to mitigate. The distinction is set out in The Three-Tiered Engine of Hazard Identification.

What you receive

  • A clear account of what happened and what was supposed to happen.
  • Root and contributing causes, separated from each other and evidenced.
  • Findings against applicable regulations, standards and industry practice.
  • Recommended control measures aimed at the conditions that enabled the event, prioritised so you know what to address first.

When to bring in someone independent

Internal investigations run into predictable difficulties. The people best placed to investigate often own the process under examination. Findings that implicate resourcing decisions are awkward to raise internally. And where an event carries regulatory, insurance or legal exposure, an independent investigation carries weight that an internal one does not.

An outside investigator also arrives without the expert blindness that develops in any operation where the same conditions have been normal for years. That effect is worth understanding in its own right, and I have written about it in The Fresh Eyes Advantage.

Frequently asked questions

What is your investigation process?

An investigation must clearly define what happened, what was supposed to happen, and why there was a difference. It examines the event, the company's systems, processes and procedures, regulatory and industry standards, and industry best practice. A thorough investigation identifies the conditions that enabled the event and recommends controls to prevent recurrence.

Do you investigate incidents that did not cause an injury?

Yes, and these are often the more valuable investigations. An organization that only examines events that caused harm is reacting to outcomes rather than managing risk. Near misses and deviations from the expected process expose the same conditions before somebody gets hurt.

Will the investigation identify who was at fault?

It will identify what happened and why, including where individual actions contributed. But an investigation that stops at individual fault leaves the enabling conditions intact, so the focus is on what allowed the event to occur and what will stop it happening again.

Can you work alongside our internal investigation?

Yes. Sometimes the appropriate role is to lead the investigation, and sometimes it is to review or support work your own team is doing. Which makes sense depends on the severity of the event, the exposure involved, and how close your investigators are to the process being examined.

Start with a conversation

Every engagement begins with a needs assessment, and that starts with a conversation about what your operation actually does and what you already have in place. Get in touch and we can work out whether this is the right fit.