Incident Investigation and Analysis
Core concepts
Incident investigation finds root causes to prevent recurrence, not to assign blame. Know the difference between an incident, an accident, and a near miss. Understand the investigation steps: secure the scene, preserve evidence, gather facts through interviews and records, analyse causes, recommend corrective actions, and follow up.
Analysis methods
Know common tools: 5 Whys, fishbone (Ishikawa) diagrams, and fault tree analysis. Distinguish immediate causes (unsafe acts, conditions) from root causes (management systems, design, culture). Corrective actions should address root causes and be tracked to closure.
Traps in questions
- Stopping at the immediate cause or blaming the worker.
- Confusing correlation with causation.
- Recommending retraining as the only fix when the system failed.
- Forgetting to verify that corrective actions worked.
Rule of thumb
Ask 'why' until you reach a system condition you can change. If the answer is 'the worker was careless', you have not finished.
Worked example
A worker slips on a wet floor. Immediate cause: wet floor. Root cause analysis reveals a leaking pipe and no inspection schedule. The correct action is to repair the pipe and add inspection, not just to retrain the worker.