Interactive graph
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.
- Level 1: After something breaks, ask what in the setup caused it - not only who was standing nearby when it happened.
- Level 2: Blameless tone keeps investigation on system causes - people fix processes when they are not scapegoated, like fixing the leaky pipe instead of yelling at the puddle.
- Level 3: Blame chases a name; investigation chases the condition that made failure possible - fix the layout, not just the person present.
- Level 4: Run post-incident reviews for system causes first - who was nearby is context, not the root.
- Level 5: 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.
Examples
- After the equipment cart tipped they traced storage layout and weight limits, not just “trainer was clumsy.”
- 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 |
