Course Topic: Advanced Incident Investigation
Timing: 14-15, December, 2017
Course Outline for Incident Investigation：
1.A Failure to learn – why we need to question our approach to understanding incident causation
2.Different accident models—is there a right answer?
3.Simple answers – why are they attractive but at the same time limited in what they tell us about why things go wrong?
4.Human bias and how this has the potential to affect our understanding and learning.
5.Human factors—what lies behind errors and violations? ABC and Human Error Analysis
1.Organisations as complex systems and how this can help us to understand incident occurrence - systems thinking
2.Looking for explanations rather than causes
3.Interview skills – avoiding the human bias pitfalls
4.Case study—a chance to apply the learning.
Benefits of Attending
● We will discuss the concept of CAUSE and its usefulness—and consider whether a focus on
EXPLANATIONS makes more sense.
● “BEHAVIOUR causes more than 90% of incidents” - we will challenge this statement and discuss how it
may hinder rather than help understanding.
● We will provide the means for you to be more explicit with respect to the different types of ERRORS and
VIOLATIONS that might be involved in an incident.
● You will be introduced to the idea of ERROR PROBABILITY and the factors that affect this.
● We will focus on a range of issues (HUMAN BIAS) all of which have the potential to affect our
● We will consider the idea that some serious incidents might be better understood as NORMAL
consequences of COMPLEX organisations.
● You will be introduced to BEHAVIOURAL MAPPING as a technique to understand complexity.
● You will experience a lively and challenging workshop with opportunities to share ideas and network with