SafetyInsights.org

This compendium covers a few elements of investigations, investigation limitations and biases, priming, underreporting and more.

Because of the breadth of these topics, this sample is pretty limited and biased to my own interests and what I’ve either written about or could find a full-text link for.

It also doesn’t cover many investigation methods (if people want one then maybe that can be a future article).

It includes:

• Investigation & Corrective Action Limitations
• Investigation Bias, Blame & Priming
• Investigation Other
• Accident Underreporting

Next compendium will likely be prospective learning focused.

Shout me a coffee

Investigation & Corrective Actions Limitations

Risk Controls Identified in Action Plans Following Serious Incident Investigations in Secondary Care: A Qualitative Study

Accident Investigations – Missed Opportunities

The process and perspective of serious incident investigations in adult community mental health services: integrative review and synthesis

Investigation recommendations and the hierarchy of control

Incident investigations not found to improve safety or quality in new data

The context and habits of accident investigation practices: A study of 108 Swedish investigators

Exploring the “Black Box” of Recommendation Generation in Local Health Care Incident Investigations: A Scoping Review

Myths of logical and impartial investigations and safety as no.1 priority: Besnard & Hollnagel 2012

Risk accommodation and preference for continual investigation over continual improvement

Has the pendulum swung too far in investigations and safety?

ICAM, construction investigations, and false dawns

Analytical traps in accident investigations

Overlooking causes in healthcare accident investigation: Choosing the analysis is choosing the results

Evaluation of Learning Teams Versus Root Cause Analysis for Incident Investigation in a Large United Kingdom National Health Service Hospital

Accident investigation reporting deficiencies related to organizational factors in machinery space fires and explosions

Practitioners’ perspectives on incident investigations

To err is system; a comparison of methodologies for the investigation of adverse outcomes in healthcare

Challenging the immediate causes: A work accident investigation in an oil refinery using organizational analysis

Can we examine safety culture in accident investigations, or should we?

Factors affecting learning from incidents: A cross-industry review

How Much of Root Cause Analysis Translates into Improved Patient Safety: A Systematic Review

How not to investigate an accident

Preventing Serious Injuries & Fatalities: Study Reveals Precursors & Paradigms

Understanding Human Error in Naval Aviation Mishaps

Fix and forget or fix and report: a qualitative study of tensions at the front line of incident reporting

Fatal and severe accidents: SIF precursors, and disconnected corrective actions and improvement

The imperfections of accident analysis

Cognitive traps: the case of omissions in the genesis of work accidents

How Effective Are Incident-Reporting Systems for Improving Patient Safety? A Systematic Literature Review

Process accidents and the use of weaker corrective actions and improvements

The Lessons We (Don’t) Learn: Counterfactual Thinking and Organizational Accountability after a Close Call

Successful risk assessment may not always lead to successful risk control: A systematic literature review of risk control after root cause analysis

How much of Root Cause Analysis translates to improve patient safety: A systematic review

Why don’t organisations learn from incidents?

What you find is not always what you fix—How other aspects than causes of accidents decide recommendations for remedial actions

Application of Human Factors Analysis and Classification System (HFACS) to UK rail safety of the line incidents

Too little and too late: A commentary on accident and incident reporting systems

Use of the Generating Options for Active Risk Control (GO-ARC) Technique can lead to more robust risk control options

Problems with incident reporting – Reports lead rarely to recommendations

Learning from incidents: Practices at a Scandinavian refinery

Lifting the lid on root cause analysis – A document analysis

The problem with root cause analysis

The problem with incident reporting

Are root cause analyses recommendations effective and sustainable? An observational study

The problem with ‘5 whys’

Our current approach to root cause analysis: is it contributing to our failure to improve patient safety?

Never Events: The Cultural and Systems Issues that cannot be Addressed by Individual Action Plans

https://www.tesble.com/10.1016/s0925-7535(00)00036-9

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Investigation Bias & Priming

Agentive Language in Accident Investigation: Why Language Matters in Learning from Events

How does leading eyewitness statements influence attributions of blame in investigations? Does blame shift between people?

Trust but verify: The biasing effects of witness opinions and background knowledge in workplace investigations

https://doi.org/10.1016/j.jsr.2023.07.012

The unintended consequences of no blame ideology for incident investigation in the US construction industry

Confirmation bias and other systemic causes of wrongful convictions: A sentinel events perspective

Measuring base-rate bias error in workplace safety investigators

A Bottom-Up Approach to Understanding the Efficacy of Event-Analysis in Healthcare: Paradigm Shift from Safety to Resilience Engineering

Nature of Blame in Patient Safety Incident Reports: Mixed methods analysis of a national database

Problems with incident reporting – Reports lead rarely to recommendations

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Investigation Other

Narratives in incident investigations found to outperform structured categorised factors in accident prediction

Tracing New Safety Thinking Practices in Safety Investigation Reports

The folly and blame of objectivist and rationalistic investigations – the Waterfall train accident

The psychology of accident investigation: epistemological, preventive, moral and existential meaning-making

https://www.researchgate.net/profile/Johan-Bergstroem/publication/335162893_The_Discursive_Effects_of_Safety_Science/links/650ad3d6d5293c106cca099b/The-Discursive-Effects-of-Safety-Science.pdf#page=224

Click to access Modern-accident-investigation-Four-major-challenges.pdf

Click to access accident_investigation_dien_et_al_2012.pdf

Click to access FDM_LFI_Paper_Author_Accepted_1_.pdf

https://d1wqtxts1xzle7.cloudfront.net/33934626/SS_70_2014_89-98_Identifying_patterns_of_safety_related_incidents_in_a_steel_plant-libre.pdf?1402612515=&response-content-disposition=inline%3B+filename%3DIdentifying_patterns_of_safety_related_i.pdf&Expires=1739604549&Signature=Cklv69v9Y91fzxX0cvzywLfppwm9eF5CFT0BVoA6JmrSxekr2NruGVEGS2BBgbSk7TE4YyFQ7DKiufJt-pvzx9tJ2l9ARmUdi2-AOmo20Ounr1P9IGUWmw9IDnuwreiLRMS8LdEyBkrBW4EGsW4W9I5HHnXVEkmWB5E4Ivds~2LtCutYBBiAGyr6i0suJMWPAJ1m9MjUCC~y1MunPoGTGq1X2waxI6nMJh-dmBkzv7FNclouQlG18ErxdE0sUAk15buMxop01~4eDTnHHUgvJpRaRwZDjJO8OiHeyBGf6UN31OO2crweie2TopWAcTBgPFBN6SPWd8NbC1FEQRugXQ__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA

https://doi.org/10.1016/j.ssci.2011.01.008

https://citeseerx.ist.psu.edu/document?repid=rep1&type=pdf&doi=b5261d18c7dc4ea260d93570c1f67c845b401cb9

https://riuma.uma.es/xmlui/bitstream/handle/10630/28338/Salguero-Caparros%20et%20al.%202015.pdf?sequence=1&isAllowed=y

Click to access What_do_applications_of_system_thinking_analysis_methods_tell_us_about_accident_causation_SAFETY_SCIENCE_2019.pdf

Click to access Back-to-the-future-What-do-accident-causation-models-tell-us-about-accident-prediction-Eryn-Grant-Paul-M-Salmon-Nicholas-J-Stevens-Natassia-Goode-Gemma-J-Read.pdf

Click to access sf-acc-prepr.pdf

Click to access 27698772.pdf

Click to access Moura_etal_SS2016_Learning_past_accidents_improve_system_design.pdf

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Accident Underreporting

Inaccuracy and misdirected decisions-making in incident reporting systems

Accident underreporting and the influence of safety climate

Accident under-reporting among employees: Testing the moderating influence of psychological safety climate and supervisor enforcement of safety practices

Emotional contagion as a trigger for moral disengagement: Their effects on workplace injuries

Voices carry: Effects of verbal and physical aggression on injuries and accident reporting

Is it safe to be safe? Examining Underreporting and Presenteeism Among European Pilots: The Role of Employment Type

Underreporting of workers’ injuries or illnesses and contributing factors – a systematic review

Occupational Injury and Illness Surveillance: Conceptual Filters Explain Underreporting

Are we missing the near misses in the OR?—underreporting of safety incidents in pediatric surgery

Assessment of underreporting factors on construction safety incidents in US construction projects

Under-reporting of non-fatal occupational injuries among precarious and non-precarious workers in Sweden

Safety Culture, Moral Disengagement, and Accident Underreporting

Pressure to produce = pressure to reduce accident reporting?

LinkedIn post: https://www.linkedin.com/posts/benhutchinson2_this-mini-compendium-covers-investigations-activity-7299873221485502465-FKnq?utm_source=share&utm_medium=member_desktop&rcm=ACoAAAeWwekBvsvDLB8o-zfeeLOQ66VbGXbOpJU