The investigation should establish what happened. But the greater opportunity is to understand how the conditions, decisions, controls and work came together to produce the outcome.
NewEra combines rigorous investigation with Human Performance, barrier analysis and learning from work to help organisations move beyond finding causes — and make better decisions about what happens next.
An incident is an outcome.
Not an explanation.
Something happened.
Someone was injured.
A control failed.
Equipment was damaged.
A release occurred.
A serious event was narrowly avoided.
The outcome is visible.
The conditions that produced it may be much harder to see.
Investigation needs to work backwards carefully.
What happened?
What was supposed to happen?
What actually happened?
What controls were relied upon?
What conditions shaped the work?
What changed?
What made people's actions and decisions make sense at the time?
What prevented the outcome from being worse?
What does the organisation need to learn?
Don't stop at the event. Understand the system around it.
Establish the facts.
Learning doesn't replace disciplined investigation.
Start with evidence.
People.
Physical evidence.
Documents.
Systems.
Data.
Images.
Equipment.
Records.
Timelines.
Plans.
Procedures.
Communications.
Control information.
Relevant technical evidence.
Build the clearest picture possible while distinguishing:
WHAT WE KNOW
Evidence supports it.
WHAT WE THINK
Evidence suggests it.
WHAT WE DON'T YET KNOW
More information is needed.
Good learning starts with good evidence.
Build the story of the work.
A timeline shouldn't simply record the moments immediately before the event.
Go further back.
How was the work planned?
What assumptions existed?
What equipment was available?
What information was provided?
What conditions changed?
What decisions were made upstream?
What adaptations had become normal?
Were there previous signals?
What happened during the work?
What happened after conditions began to change?
A useful timeline shows how the situation developed.
The event has a history.
Understand normal work first.
To understand why something went wrong, understand how the work normally succeeds.
Ask:
How is this task usually performed?
What normally changes?
Where do people use judgement?
What workarounds are common?
What makes the task difficult?
What normally keeps it safe?
What do experienced people know that isn't written down?
Without that context, normal adaptations can easily be mistaken for unusual behaviour simply because an event occurred.
Avoid hindsight.
After an incident, the important information can appear obvious.
It wasn't necessarily obvious beforehand.
The outcome changes what we notice.
A warning sign now appears clear.
A decision now looks questionable.
A control weakness now seems predictable.
A different action now feels inevitable.
Investigation needs to reconstruct the situation people faced before they knew the outcome.
Ask:
What could they see?
What did they know?
What were they expecting?
What information was available?
What goals were they balancing?
What options appeared reasonable?
Understanding isn't the same as excusing.
It is necessary if we want to prevent recurrence.
Human error is the beginning of the enquiry.
“Operator error.”
“Failed to follow procedure.”
“Poor judgement.”
“Lack of situational awareness.”
“Complacency.”