Root cause investigation, corrective actions that address the system rather than the person, and a closure process that holds — plus serious injury and fatality exposure analysis when the near misses are telling you something.
If the finding is that someone was careless and the action is retraining, the investigation stopped one question early. Why was the error possible, and why was it survivable, are the questions that change outcomes.
Actions land in a report with no assignment and no deadline. Six months later the same incident repeats and the open action is discoverable.
The severity of an injury is largely luck. Investigating only what happened to hurt someone means ignoring the near misses that describe your next fatality.
Most serious injuries and fatalities come from a small subset of exposures that look no different in the incident log. Without flagging SIF potential, a high-potential near miss gets the same attention as a paper cut.
A supervisor investigating an incident in their own area faces an obvious conflict. Findings that implicate staffing, schedule pressure or equipment decisions rarely survive that structure.
Individual investigations without aggregate analysis miss the pattern. The same contributing factor across eleven incidents is the finding, and nobody sees it one report at a time.
We build the investigation process — trigger criteria, team composition, a root cause method your people can actually use, SIF potential flagging, and a corrective action register with owners, dates and verification of effectiveness rather than just completion.
For serious incidents, we run the investigation ourselves. An outside credentialed investigator surfaces contributing factors that an internal team is structurally unable to raise.
Whichever one your people will actually complete. A well-run five whys beats an abandoned fault tree. For serious incidents the method should be more structured, which is a reason to bring in outside facilitation for those.
Yes, with proportional effort — screened for SIF potential rather than investigated identically. A near miss involving a defeated interlock deserves far more attention than a slip on a wet floor.
By making reporting easy, responding visibly, and never disciplining someone for reporting. Reporting volume drops to zero after one punitive response and takes years to recover.
Generally yes in litigation. That is an argument for investigating well and closing actions, not for investigating poorly. Open unaddressed findings are the real exposure.
Yes, though evidence degrades quickly. The sooner the better, and we can work from existing documentation and interviews where the scene is gone.
Count how many concluded with retraining. Twenty minutes to talk about what that number means.
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