Incident Investigation – Learning From the Past to Change the Future

Our journey towards Zero Harm implies that incidents will not occur, and certainly if they do occur, they will not occur again. Zero Harm has a clear focus on the future. People at all levels of organisations express a desire to prevent recurrence. They repeatedly declare that investigations are not “finger pointing exercises”. Many, however, hold their head in their hands as incidents recur and declare “Why aren’t we fixing this problem?” What is not appreciated is the very models and processes they use for incident investigation subtly and subconsciously promote laying blame and the implementation of ineffective administrative controls. More training, more tool boxes, more paperwork. Words such as cause and human error need to be replaced with words and models that focus our attention on changing the future not blaming for the past.

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