Mini-Compendium: Investigations & Corrective Action Limitations / Bias / Underreporting

Mini-Compendium: Investigations & Corrective Action Limitations / Bias / Underreporting

Ben Hutchinson Ben Hutchinson

Ben Hutchinson

HSE Leader / PhD Candidate

发布日期: 2025年2月24日
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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.


Please like, comment and share, as this article has external links and I fear the algorithm demi-gods will smite me.


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


If you'd like to support my site, then feel free to shout a coffee:

Next compendium will likely be prospective learning focused.

Investigation & Corrective Actions Limitations


https://safety177496371.wordpress.com/2024/08/12/risk-controls-identified-in-action-plans-following-serious-incident-investigations-in-secondary-care-a-qualitative-study/

https://safety177496371.wordpress.com/2024/07/09/accident-investigations-missed-opportunities/

https://safety177496371.wordpress.com/2024/05/15/the-process-and-perspective-of-serious-incident-investigations-in-adult-community-mental-health-services-integrative-review-and-synthesis/


https://safety177496371.wordpress.com/2023/10/29/investigation-recommendations-and-the-hierarchy-of-control/

https://safety177496371.wordpress.com/2023/10/21/incident-investigations-not-found-to-improve-safety-or-quality-in-new-data/


https://safety177496371.wordpress.com/2023/06/30/the-context-and-habits-of-accident-investigation-practices-a-study-of-108-swedish-investigators/


https://safety177496371.wordpress.com/2023/10/25/exploring-the-black-box-of-recommendation-generation-in-local-health-care-incident-investigations-a-scoping-review/

https://safety177496371.wordpress.com/2023/01/31/myths-of-logical-and-impartial-investigations-and-safety-as-no-1-priority-besnard-hollnagel-2012/


https://safety177496371.wordpress.com/2023/01/12/risk-accommodation-and-preference-for-continual-investigation-over-continual-improvement/


https://safety177496371.wordpress.com/2022/11/25/has-the-pendulum-swung-too-far-in-investigations-and-safety/


https://safety177496371.wordpress.com/2022/06/10/icam-construction-investigations-and-false-dawns/


https://safety177496371.wordpress.com/2022/05/06/analytical-traps-in-accident-investigations/

https://safety177496371.wordpress.com/2022/04/07/overlooking-causes-in-healthcare-accident-investigation-choosing-the-analysis-is-choosing-the-results/


https://safety177496371.wordpress.com/2022/03/08/evaluation-of-learning-teams-versus-root-cause-analysis-for-incident-investigation-in-a-large-united-kingdom-national-health-service-hospital/


https://safety177496371.wordpress.com/2022/03/01/accident-investigation-reporting-deficiencies-related-to-organizational-factors-in-machinery-space-fires-and-explosions/


https://safety177496371.wordpress.com/2021/10/19/practitioners-perspectives-on-incident-investigations/


https://safety177496371.wordpress.com/2021/08/31/to-err-is-system-a-comparison-of-methodologies-for-the-investigation-of-adverse-outcomes-in-healthcare/


https://safety177496371.wordpress.com/2021/06/17/challenging-the-immediate-causes-a-work-accident-investigation-in-an-oil-refinery-using-organizational-analysis/


https://safety177496371.wordpress.com/2021/06/14/can-we-examine-safety-culture-in-accident-investigations-or-should-we/


https://safety177496371.wordpress.com/2025/01/31/factors-affecting-learning-from-incidents-a-cross-industry-review/


https://safety177496371.wordpress.com/2024/07/30/how-much-of-root-cause-analysis-translates-into-improved-patient-safety-a-systematic-review/

https://safety177496371.wordpress.com/2024/07/05/how-not-to-investigate-an-accident/

https://safety177496371.wordpress.com/2024/06/24/preventing-serious-injuries-fatalities-study-reveals-precursors-paradigms/


https://safety177496371.wordpress.com/2024/06/21/understanding-human-error-in-naval-aviation-mishaps/


https://safety177496371.wordpress.com/2024/06/10/fix-and-forget-or-fix-and-report-a-qualitative-study-of-tensions-at-the-front-line-of-incident-reporting/

https://safety177496371.wordpress.com/2024/06/04/fatal-and-severe-accidents-sif-precursors-and-disconnected-corrective-actions-and-improvement/

https://safety177496371.wordpress.com/2024/05/28/the-imperfections-of-accident-analysis/

https://safety177496371.wordpress.com/2024/05/27/cognitive-traps-the-case-of-omissions-in-the-genesis-of-work-accidents/


https://safety177496371.wordpress.com/2024/03/24/how-effective-are-incident-reporting-systems-for-improving-patient-safety-a-systematic-literature-review/


https://safety177496371.wordpress.com/2023/11/05/process-accidents-and-the-use-of-weaker-corrective-actions-and-improvements/


https://safety177496371.wordpress.com/2023/07/26/the-lessons-we-dont-learn-counterfactual-thinking-and-organizational-accountability-after-a-close-call/


https://safety177496371.wordpress.com/2023/06/09/successful-risk-assessment-may-not-always-lead-to-successful-risk-control-a-systematic-literature-review-of-risk-control-after-root-cause-analysis/


https://safety177496371.wordpress.com/2023/05/26/how-much-of-root-cause-analysis-translates-to-improve-patient-safety-a-systematic-review/


https://safety177496371.wordpress.com/2023/05/06/why-dont-organisations-learn-from-incidents/

https://safety177496371.wordpress.com/2023/04/21/what-you-find-is-not-always-what-you-fix-how-other-aspects-than-causes-of-accidents-decide-recommendations-for-remedial-actions/


https://safety177496371.wordpress.com/2023/04/19/application-of-human-factors-analysis-and-classification-system-hfacs-to-uk-rail-safety-of-the-line-incidents/


https://safety177496371.wordpress.com/2022/10/25/too-little-and-too-late-a-commentary-on-accident-and-incident-reporting-systems/


https://safety177496371.wordpress.com/2022/06/16/use-of-the-generating-options-for-active-risk-control-go-arc-technique-can-lead-to-more-robust-risk-control-options/


https://safety177496371.wordpress.com/2022/04/05/problems-with-incident-reporting-reports-lead-rarely-to-recommendations/


https://safety177496371.wordpress.com/2022/01/24/learning-from-incidents-practices-at-a-scandinavian-refinery/


https://safety177496371.wordpress.com/2021/08/24/lifting-the-lid-on-root-cause-analysis-a-document-analysis/


https://safety177496371.wordpress.com/2021/07/29/the-problem-with-root-cause-analysis/


https://safety177496371.wordpress.com/2021/06/29/the-problem-with-incident-reporting/


https://safety177496371.wordpress.com/2021/05/04/are-root-cause-analyses-recommendations-effective-and-sustainable-an-observational-study/


https://safety177496371.wordpress.com/2021/04/29/the-problem-with-5-whys/


https://safety177496371.wordpress.com/2021/03/18/our-current-approach-to-root-cause-analysis-is-it-contributing-to-our-failure-to-improve-patient-safety/


https://safety177496371.wordpress.com/2021/03/04/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

Investigation Bias & Priming


https://safety177496371.wordpress.com/2024/06/26/agentive-language-in-accident-investigation-why-language-matters-in-learning-from-events/


https://safety177496371.wordpress.com/2024/05/12/how-does-leading-eyewitness-statements-influence-attributions-of-blame-in-investigations-does-blame-shift-between-people/


https://safety177496371.wordpress.com/2023/12/06/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


https://safety177496371.wordpress.com/2023/07/12/the-unintended-consequences-of-no-blame-ideology-for-incident-investigation-in-the-us-construction-industry/


https://safety177496371.wordpress.com/2024/06/06/confirmation-bias-and-other-systemic-causes-of-wrongful-convictions-a-sentinel-events-perspective/


https://safety177496371.wordpress.com/2023/10/02/measuring-base-rate-bias-error-in-workplace-safety-investigators/


https://safety177496371.wordpress.com/2023/09/22/a-bottom-up-approach-to-understanding-the-efficacy-of-event-analysis-in-healthcare-paradigm-shift-from-safety-to-resilience-engineering/


https://safety177496371.wordpress.com/2022/08/11/nature-of-blame-in-patient-safety-incident-reports-mixed-methods-analysis-of-a-national-database/


https://safety177496371.wordpress.com/2022/04/05/problems-with-incident-reporting-reports-lead-rarely-to-recommendations/


Investigation Other


https://safety177496371.wordpress.com/2024/07/25/narratives-in-incident-investigations-found-to-outperform-structured-categorised-factors-in-accident-prediction/


https://safety177496371.wordpress.com/2024/07/01/tracing-new-safety-thinking-practices-in-safety-investigation-reports/


https://safety177496371.wordpress.com/2024/03/24/the-folly-and-blame-of-objectivist-and-rationalistic-investigations-the-waterfall-train-accident/


https://safety177496371.wordpress.com/2024/06/25/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


https://www.researchgate.net/profile/Sverre-Roed-Larsen/publication/257356434_Modern_accident_investigation_-_Four_major_challenges/links/5ddbdc8f458515dc2f4ca6ff/Modern-accident-investigation-Four-major-challenges.pdf


https://www.forumat.net.br/at/sites/default/files/arq-paginas/accident_investigation_dien_et_al_2012.pdf

https://pure.hw.ac.uk/ws/portalfiles/portal/15636032/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://d1wqtxts1xzle7.cloudfront.net/47478984/j.ssci.2011.01.00820160724-9069-1xuzm74-libre.pdf?1469377337=&response-content-disposition=inline%3B+filename%3DThe_complexity_of_failure_Implications_o.pdf&Expires=1739604513&Signature=c-pYdHGElQyaWwBRqcPI0RkMP2FQpqeurcVQe-Hccy9iKtt3LY8kpeJyXkCTsOXJOe4XVuujIkv6RbLgsp3QXDVLLar2pIwpc4qOdnzZHUN1HHg7hcWktVDkyy8GIfGMrBOj0Aeg5oBCSkgaAtDKhAgML9XHNvI6N6kElA~nozT09TNeEAId1En9PRtEypafNONq~C8aCuQqAw6dL9Xyy6DZXUGvQ1XistpAKfPRhG2PfJ8aI-trfL4S7usS-Ofktn70shKNxFE3zY3V0r~JsBrhR2KH~nWUbs9QD64gP8~22OUyNXMR8pq173SrcqMAnrjDbmaWdhifxVAr~xFx2Q__&Key-Pair-Id=APKAJLOHF5GGSLRBV4ZA

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

https://eprints.soton.ac.uk/432439/1/What_do_applications_of_system_thinking_analysis_methods_tell_us_about_accident_causation_SAFETY_SCIENCE_2019.pdf


https://www.prlinnovacion.com/wp-content/uploads/2020/11/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


https://www.irisk.se/engpubl/sf-acc-prepr.pdf


https://repository.lboro.ac.uk/articles/journal_contribution/Improving_accident_analysis_in_construction_Development_of_a_contributing_factor_classification_framework_and_evaluation_of_its_validity_and_reliability/14472900/1/files/27698772.pdf


https://pure.strath.ac.uk/ws/portalfiles/portal/91853072/Moura_etal_SS2016_Learning_past_accidents_improve_system_design.pdf


Accident Underreporting


https://safety177496371.wordpress.com/2024/03/28/inaccuracy-and-misdirected-decisions-making-in-incident-reporting-systems/


https://safety177496371.wordpress.com/2023/01/28/accident-underreporting-and-the-influence-of-safety-climate/

https://safety177496371.wordpress.com/2021/12/13/accident-under-reporting-among-employees-testing-the-moderating-influence-of-psychological-safety-climate-and-supervisor-enforcement-of-safety-practices/

https://safety177496371.wordpress.com/2021/08/10/emotional-contagion-as-a-trigger-for-moral-disengagement-their-effects-on-workplace-injuries/


https://safety177496371.wordpress.com/2021/07/06/voices-carry-effects-of-verbal-and-physical-aggression-on-injuries-and-accident-reporting/


https://safety177496371.wordpress.com/2024/04/30/is-it-safe-to-be-safe-examining-underreporting-and-presenteeism-among-european-pilots-the-role-of-employment-type/


https://safety177496371.wordpress.com/2023/05/18/underreporting-of-workers-injuries-or-illnesses-and-contributing-factors-a-systematic-review/


https://safety177496371.wordpress.com/2023/02/08/occupational-injury-and-illness-surveillance-conceptual-filters-explain-underreporting/


https://safety177496371.wordpress.com/2022/06/23/are-we-missing-the-near-misses-in-the-or-underreporting-of-safety-incidents-in-pediatric-surgery/


https://safety177496371.wordpress.com/2021/02/20/assessment-of-underreporting-factors-on-construction-safety-incidents-in-us-construction-projects/


https://safety177496371.wordpress.com/2022/06/08/under-reporting-of-non-fatal-occupational-injuries-among-precarious-and-non-precarious-workers-in-sweden/


https://safety177496371.wordpress.com/2021/06/28/safety-culture-moral-disengagement-and-accident-underreporting/


https://safety177496371.wordpress.com/2021/02/10/example-post/



Warren Smith

Helping organisations with hazardous workplaces work toward a harm-free environment

3 天前

What a great set of resources, Ben - many thanks for pulling this together!

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Ben Hutchinson

HSE Leader / PhD Candidate

3 天前

Charles Major this may interest your CHOL community

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Ben Hutchinson

HSE Leader / PhD Candidate

3 天前

Paul Clark, Tom McDaniel, Ben Evans this may interest you. I have a prospective learning compendium coming up in the next week or two also, not coupled to investigations.

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Mark Alston

Executive Director & Facilitator | Incident and Workplace Investigations | Risk Management | Workplace Health & Safety | Investigations, Training, Research & Analysis

4 天前

Thanks, Ben Hutchinson, for another great share.?Unfortunately, the objective of most investigations is to 'identify root causes to prevent recurrence'.?(Arguably almost impossible.) They are not looking to reduce risk. This drives linear thinking and not the exploration of uncertainty.?Nothing will improve until organisations change what they want an investigation to achieve.

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