Incident investigation is a central role of safety professionals and a vital process for safety management in organisations. However, despite their importance, incident investigation processes often need to be more effective as learning tools across organisations. In this blog post, we will explore what an effective incident investigation process looks like, the science of human factors and the theory of just culture as they relate to incident management and investigation.

The Four Key Steps of an Incident Investigation Process

An effective incident investigation process involves four key steps: incident description, identification of causes, identification of changes to the organisation and work processes, and learning.

Step One: Incident Description.

After an unexpected event or a surprise related to safety in your organisation, it is crucial to understand what happened in as much detail as possible. The people involved in the incident know the most about the situation and should be considered your best resource. It is essential not just to look at the incident itself but also to explore everyday work related to the tasks involved comprehensively.

Step Two: Identification of Causes.

All incidents have multiple causes. There is no such thing as one root cause; if there were, we would have solved all safety problems by now. Identifying the variables that contributed to the circumstances that created the incident is essential. It is crucial to look deeply and non-judgmentally at the actions of all the people involved. Why did it make sense for them to make the decisions they did? Why did it make sense for them to do the work the way they did?

Step Three: Identification of Changes.

We then need to identify changes we want to make to how the organisation functions and how that work is done due to the incident. Recommended actions should always start with the outcome being sought and how it's different from what's currently happening in your organisation. This step is crucial as it allows validation that the identified actions will deliver the desired outcome.

Step Four: Learning.

Learning is sharing and institutionalising the knowledge gained and the decisions made during the incident investigation process. For understanding to occur, there needs to be a two-way open communication process between people in a way that challenges their thoughts and assumptions about work.

The Science of Human Factors and the Theory of Just Culture

Human factors are directly relevant to incident investigations and safety management more broadly. There are five exciting questions in human factors related to the incident investigation: Was it a mechanical failure or a human error? Why do safety systems fail? Don't errors exist? If you lose situational awareness, what replaces it? Why don't they follow the procedures?

The most critical aspect of your organisation that will determine the value and the learning you get from your incident investigation process is not your investigators' capability; it's your organisation's culture. More specifically, to what extent do you have a just culture? A just culture is an environment where learning and accountability are fairly balanced. However, the term just culture is often misused, misunderstood, and misrepresented. It relates to one of two extreme positions: either individuals should be disciplined if management followed the organisation's just culture process, or individuals should never be held accountable for their behaviours.

Neither of these two positions describes what a just culture is. A just culture lies between culpable and blameless. The real challenge in learning opportunities lies in understanding the complexity of the event and determining the level of accountability of individuals involved.
A just culture is not about protecting individuals from consequences but rather about understanding the systemic factors that contributed to the incident and addressing those to prevent similar incidents in the future. It is about creating a culture where individuals feel comfortable reporting incidents and accidents to stop them from happening in the future. A just culture also recognises that individuals can make mistakes, but those mistakes should not be used to punish or blame them but rather to learn from and improve the system.

Open and transparent communication is one of the critical components of a just culture. This means that individuals feel safe to report incidents and errors without fear of retaliation. It also means that the organisation is open and transparent about the incident investigation process, findings, and actions to prevent similar incidents.

Another key component of a just culture is accountability. This means that individuals and the organisation as a whole are held accountable for their actions and decisions. However, it also means that accountability is proportionate to the individual's level of involvement and responsibility. It is not about finding someone to blame but rather about understanding the factors that contributed to the incident and addressing them to prevent similar incidents.

In conclusion, the incident investigation is a crucial process for safety management in organisations. However, it is often ineffective as a learning tool due to a need for more understanding of human factors and just culture. An effective incident investigation process involves four key steps: incident description, identification of causes, identification of changes to the organisation and work processes, and learning.

The science of human factors and the theory of just culture play a crucial role in incident management and investigation. A just culture is an environment where learning and accountability are fairly balanced, and organisations must create such a culture to make incident investigation effective.

Enhance Workplace Safety and Learning with an Effective Incident Investigation Process and a Just Culture

Work Safety Hub recognises the importance of a thorough and efficient incident investigation process as a cornerstone of safety management in organisations. Our expert team is dedicated to helping you implement an effective incident investigation process and foster a just culture, enabling your organisation to learn from incidents and improve overall safety.

Our comprehensive approach covers:

1. The Four Key Steps of an Incident Investigation Process: Incident Description, Identification of Causes, Identification of Changes, and Learning. These steps form the foundation of an effective incident investigation process, enabling your organisation to gain insights and make necessary changes in response to incidents.
2. The Science of Human Factors and the Theory of Just Culture: Understanding human factors and creating a just culture are critical components of effective incident management and investigation. We help your organisation strike the right balance between learning and accountability, ensuring that individuals feel comfortable reporting incidents and accidents without fear of retaliation.

By choosing Work Safety Hub, you invest in your organisation's long-term safety and success. Our team is committed to providing the necessary guidance and expertise to develop and maintain an effective incident investigation process and a just culture in your workplace.

Discover the benefits of a robust incident investigation process and a just culture for your organisation. Contact us today for a consultation, and let us help you enhance workplace safety and learning. 

General advice warning

The information on this site is of a general nature only. It does not take your specific needs or circumstances into consideration. You should look at your own situation and requirements before making any decisions.