Category
Incident Investigation
89 articles
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.
Moura Mine Disaster: How a Known Gas Risk Became Fatal
The 1994 Moura No. 2 explosion shows why methane control, emergency readiness, and worker voice must be tested as one system before a fatal event.
Incident Investigation: 4 Questions That Reveal When the Root Cause Is Still Missing
A serious incident investigation does more than identify the last unsafe action. These four questions help leaders test whether the analysis reached failed barriers, decisions, and conditions that allowed the event to develop.
How to Write Incident Findings That Lead to Better Controls in 21 Days
A practical 21-day method for turning incident evidence into findings that name the failed control, expose decision gaps, and guide verifiable corrective action.
Post-Incident Meetings: 4 Decisions That Determine Whether People Speak Before the Story Hardens
The first post-incident meeting often determines whether the organization learns or simply confirms its first explanation. This diagnostic shows four decisions that protect psychological safety, preserve evidence, and keep the causal story open long enough to become useful.
How Flixborough Exposed the Cost of Treating Design Change as a Local Fix
The Flixborough disaster was not only a story about a failed pipe. It was a case study in how a local design change can outrun engineering control, review, and organizational authority.
New Incident Investigator in 60 Days: What to Do in the First Investigation Cycle
A practical 60-day transition plan for a newly appointed incident investigator who needs to protect evidence, earn trust, and turn findings into stronger controls.
How to Build an Incident Investigation Charter Before Interviews Begin
A short investigation charter gives the team a shared scope, evidence standard, decision owner, and interview sequence before early assumptions harden. This eight-step guide shows supervisors, EHS managers, and incident leads how to build one without turning the investigation into paperwork.