Incident Investigation and Root Cause Analysis

About this course.

We investigate incidents to learn what went wrong, to prevent the same thing happening again, and to meet the legal duties we owe to workers and others — not to find a single person to punish. An incident reveals a gap between how work was imagined and how it was actually done, and understanding that gap lets us fix the system so the failure cannot recur. Blame stops at the person nearest the harm, concluding that they simply "weren't careful". Cause looks past that person to the conditions, decisions and pressures that made the error likely and the harm possible. Blame feels like closure but changes nothing; cause changes the work.

The first reason to investigate is learning. Work in the built environment is complex: plant and equipment, temporary structures, changing site conditions, multiple trades, subcontractors, weather, deadlines and hundreds of small decisions interact every day. Most of the time this complexity is absorbed by people adapting, improvising and compensating, and work finishes without harm. An incident is a moment when those adaptations were not enough, and it exposes something about the system that was previously invisible — a control that was missing, a procedure that could not realistically be followed, a hazard nobody had recognised, or a piece of information that did not reach the people who needed it. If we treat that moment purely as a failure to be closed off, we throw away the information it contains. If we treat it as a source of learning, we can see how work really happens and where the system is fragile.