Investigation Course

"World class organizations do not tolerate preventable accidents"

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Our course is designed to train you on the proven methodology utilized by organizations like the NTSB, FAA and CSB which can’t afford to not learn from their incidents.  Now, it’s your turn.  Here’s what makes our methodology the best in the business. 

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​As attempting as it is to want to blame the frontline worker for their mistake, you must move beyond blaming the worker for your organization to become preventative.  To do that you must understand why we err.  Daniel Kahneman, the leading psychologist and Nobel prize winner on why people make mistakes has defined our errors (unsafe acts) through the analogy that our brain is comprised of two characters, one that thinks fast (system 1) and one that thinks slow (system 2).  Each of these systems have strengths and weaknesses.  System 1 operates automatically, intuitively and effortlessly.  This is used for routine work.  However, system 1 is plagued with biases that set us up for making errors.  Errors with a foundation in confirmation bias, plan continuation bias and normalized deviation.  While system 2 is the slower more methodical processor which deliberates and solves problems.  It is used for non-routine work.  Weaknesses in system 2 are distractions (prospective memory failure) and channelized attention which forces you to lose situational awareness. Understanding why the frontline errs moves your organization from blaming to learning.  Next, you must understand the system the worker is working within.

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James Reason established the Swiss Cheese model to demonstrate there are 4 separate levels of barriers present for an investigator to investigate:  Organizational Influences, Supervisory Factors, Preconditions and Unsafe Acts.  These 4 levels of barriers are sequential in nature, meaning that the levels at the top affect the levels below.  Within each level, failures can cause holes in your safety barriers.  These failures/holes can either be active or latent (contributing to the incident).  Latent errors are always present in a system and are only discovered through our investigative process. System Safety Investigations (SSI) translates Reason’s theory into a pragmatic framework that guides the analysis of the role of the organization all the way to the frontline’s worker error.  It is a contributing causal map to uncover the valuable latent errors in a system.  This proven Swiss Cheese systematic approach combined with a deep understanding of why we err will deliver corrective actions that are preventative to your system. 

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The SSI framework is supplemented with an example and class exercise on how to conduct a Cognitive Interview (CI) with a participant or witness.  CI is the most proven effective way to increase information about the incident or event.  It has been proven through the FBI, Interpol and police departments to generate 50% – 60% more information during the interview.  With an increase in detail surrounding the event along with the SSI framework, your organization will increase the quality of the investigative process. This quality will lead to corrective actions that will be preventative.   

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The objective of this workbook is to provide a consistent process to obtain and utilize knowledge gained from undesired events to reduce the probability and consequences of similar future events.  SSI and cognitive interviewing are the generative step change in safety that will reduce risk and improve workplace safety in your company. 

Below is the course outline:

Day 1:  Attendees will start with an exercise that sets the foundation for the principles of SSI.  Our exercise will highlight organizational failures as well as supervisory failures in an incident.  The afternoon session will cover an interviewing technique that will add 60% more detailed information from a witness.

Day 2:  The morning session will have the attendees dive deep into understanding why we err.  Highlighting the strengths and weaknesses of our decisions. The afternoon session emphasizes a key process called red teaming which improves investigations by 20%.  Once completed, your team will learn the importance of a standardized taxonomy to demonstrate the consistency when finalizing their investigation. Standard taxonomies provide a comprehensive framework for identifying accidents’ causal and contributing factors which will develop data-driven interventions, and objectively evaluate safety trends.

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Day 3:  The final day will start with sharing the best practices for writing the report.  Then, the course will wrap up with an accident and the participants using the SSI methodology to determine the cause, contributing causes and appropriate corrective actions to prevent the accident from recurrence.