Investigation Thinking

Incident investigation reports often contain phrases such as: Poor communication Human error Lack of awareness Inadequate supervision Insufficient training At first glance, these statements seem reasonable. They sound like explanations and appear to identify why the incident occurred. The problem is that they often do something dangerous: they create the impression that we understand the problem when, in reality, we have only given it a name. Organisations rarely fail to lear

Many organisations complete investigations, assign corrective actions and formally close incidents. Yet despite these efforts, similar events continue to happen. The reason is often that the corrective actions implemented are not truly effective. This raises an uncomfortable question. Are organisations truly learning from incidents … or simply managing administrative closure? The Problem with Many Corrective Actions One of the most common weaknesses in incident management is

Why effective investigators look beyond the individual and focus on the conditions that shaped the event.