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Incident Investigation
Table of Contents
Find system causes after a miss - not only who to blame.
Key Concept
- Blameless tone keeps investigation on system causes.
- Blameless After-Action Review shares the tone; Heed Every Near Miss feeds hazards before incidents land.
- Trace layout, limits, and rules - not just who was standing there when it broke.
- Fix the system before you close the file on who to blame.
Level 1 - Recognize
Incident investigation asks what in the system caused the failure - not only who was standing nearby when it broke.
Level 2 - Explain
Blameless tone keeps people fixing processes instead of hiding - like fixing the leaky pipe instead of yelling at the puddle.
Level 3 - Use
After the equipment cart tipped, trace storage layout and weight limits first - not just whether the trainer was clumsy.
Level 4 - Connect
Blame chases a name; investigation chases the condition that made failure possible - who was nearby is context, not the root cause.
Level 5 - Create
Build a blameless investigation method that traces conditions, tests the suspected cause, and turns the finding into a system change before the next incident.
Examples
- After the cart tipped they traced storage layout and weight limits, not clumsy trainer - glad the debrief fixed the hazard instead of the person.
- After the kitchen burn they traced pan placement and stove rules, not just “kid was not careful.”
Note Relationships
| Relationship | Wikilink | Reason |
|---|---|---|
| contradicts | By Their Fruits | when the opposite frame fits better |
| extends | Blameless After-Action Review | Blameless tone keeps investigation on system causes |
| extends | Heed Every Near-Miss | Investigation starts where near-misses were logged |
| extends | Own the Error | Blameless ownership feeds system-level investigation |
