Category
Incident Investigation
96 articles
Post-Incident Action Plans: 5 Decisions That Prevent Retraining Theater
A post-incident action plan should change the conditions that allowed harm, not only document retraining. Use five decisions to test ownership, barriers, evidence, and closure.
T2 Laboratories: How an Unverified Cooling Barrier Became a Runaway-Reaction Disaster
The T2 Laboratories explosion was not only an equipment failure. The CSB investigation shows how inadequate reactor cooling and unrecognized process hazards can leave a critical barrier implicit until a routine batch becomes a catastrophic event.
How the Farmington Mine Disaster Changed U.S. Mine Safety in One Year
The 1968 Farmington Mine disaster shows how a fatal event becomes a leadership test when investigation evidence is translated into law, control standards, and decision rights.
Near-Miss Review vs Incident Investigation vs Barrier Analysis: Which Method Should Drive the Next Control Decision?
Near-miss review, incident investigation, and barrier analysis answer different questions. This comparison helps EHS managers choose the method that fits the event and produces a control decision that can be verified in real work.
Near-Miss Signal Explained: 4 Evidence Levels That Separate Warning From Noise
A near miss becomes useful only when its evidence shows what barrier was tested, how close the exposure came to harm, and which conditions made the event possible. This explainer defines four evidence levels that help investigators distinguish a meaningful warning from an unverified report.
Upper Big Branch: How Production Pressure Overwhelmed Mine Safety Controls
The Upper Big Branch disaster shows how production pressure becomes fatal when ventilation, examination, maintenance, and escalation are treated as separate tasks instead of one operating control system.
Longford 1998: How a Process Upset Became a System Failure
The 1998 Esso Longford gas plant accident killed 2 people and injured 8. This documented case study explains how abnormal conditions, weak escalation, and unclear decision ownership can turn a process upset into a system failure, then gives plant leaders a practical 30-day review.
Flixborough: 3 Decisions That Turned a Temporary Modification Into a Major-Accident Pathway
The 1974 Flixborough explosion was not caused by one careless act. It developed through three management decisions that allowed a temporary process modification to operate without an engineering review proportionate to its risk.
Evidence Triangulation Explained: 4 Tests That Keep Incident Findings Defensible
Evidence triangulation helps incident investigators test a finding against independent sources before treating it as reliable. This explainer shows four practical tests that compare accounts, records, physical conditions, and the work method that was actually available.
Incident Evidence: 8 Myths That Make Investigations Less Reliable
Incident investigations become unreliable when photographs, witness accounts, timelines, and root-cause claims are treated as facts without testing their limits. These eight myths help investigators preserve evidence, separate observation from interpretation, and produce actions that address the conditions that allowed the event.