Internal investigations can be shallow in richness, relationships, and also time. Without the flow of events, ‘shallow time’ obliges...

Recently, I looked at an accident in which an experienced person did something unforeseeable. The equipment, procedure and people were...

In the UK, there is no statutory duty to investigate occupational accidents. There is, however, a duty to have a valid risk assessment....

The NRI foundation maintains the manual on Events and Conditional Factors Analysis. Investigators use it to create rigorous descriptions...

Wise Trevor Kletz advised: “Never remove equipment before you know why it was installed. Never abandon a procedure before you know why it...

How do you get value from internal investigation? Senior managers seldom investigate accidents personally. But, left to their own...

Investigators do the investigations that they can live with; that tends not to be talked about much. Instead, writers and trainers focus...

When people say ‘MORT’ they usually mean the method for evaluating safety management. MORT was also a project that, in the 1970s,...

NRI’s white paper on operational readiness presents twelve, linked principles. The first, Nertney’s principle, is to plan and manage any...

Haddon’s paper, On the Escape of Tigers, describes an orderly way to design-out the risks of accidents. Even at 50, it’s a great example...

Every now and then I am asked: “is ‘x’ a good tool?”. My NRI colleagues and I wrote about this some years ago. One conclusion was that...

The parties in a courtroom know the standard of proof for facts that is expected there. It is seldom so clear in the workplace, and often...

It is easy to set-up measurements, but also to get ensnared by them; this is the warning of the McNamara fallacy. The phrase does no...

A handful of principles can help to make writing readable. It matters, too. My colleagues and I published a paper that showed emergency...

“They might as well write the conclusions before investigating the accident,” the senior investigator despaired: “it’s really that bad”....