Incident Investigation and Learning

Learning from incidents is vital in aiding organizations in the elimination of Serious Injuries and Fatalities (SIFs).  The goal of this project was to determine what happened and why, highlighting any causal factors that led to the incident.  This approach enables organizations to learn from incidents and make appropriate changes to ensure they won’t happen again.

Most incident investigation resources focus on the analysis of data collected, and there are many different academic and commercial tools available to help with that step.  However, within these tools there is often a presumption that the information collected is itself of high quality – but that is not always the case.

Our research found that this first stage in the process is often neglected, and how to ensure high-quality information collection has not seen much attention in either research or practice.  The quality of this information is critical to the rest of the process.  Poor quality information will result in poor analysis, inform poor organizational learning and thus limit the implementation of positive change.