(66a) Getting Incident Investigations Right

When safety investigations are conducted like criminal investigations, they tend to be backward-looking and focused on learning who to blame, rather than forward-looking with a focus on what to blame, so that similar incidents can be avoided.

Unfortunately, many internal incident investigations are led by people who learned what they know about incident investigations from television police dramas, so conduct them like criminal investigations. To avoid this, some organizations arrange for third-party investigations. One advantage of a third-party investigation is that nothing is off the table. Also, there is no presumption that the cause is already known. While the viewpoint of every investigator is informed by their experience and conceptions of causation, so never “objective”, third-party investigations can bring a valuable perspective to the primary objective of incident investigations: learning how to avoid similar events in the future.

After decades of conducting incident investigations and training incident investigators, we’ve learned that there are certain pitfalls that often snare investigators, especially internal or infrequent investigators. We discuss some of those traps—from deciding which incidents to investigate and the unrecognized influence of conceptions of causation, to the nature and value of recommendations that are often made.