Incident Investigation
Something went wrong. What happens now?
An effective investigation should explain more than who made the mistake.
Safemetrics investigates incidents to understand the system behind the event.
We look at
01
The event
What happened?
02
The conditions
What was happening around the people involved?
03
The decisions
What decisions influenced the situation?
04
The controls
Which controls existed, failed or were missing?
05
The organisation
What underlying systems or assumptions contributed?
We investigate
Significant incidents
Serious near misses
Recurring incidents
Critical control failures
Complex events
Independent investigations
The outcome
A useful investigation should establish:
What happened
Why it happened
What allowed it to happen
What needs to change
How management can verify the change