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Information resides in difference

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

Polite Self-Investigations

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

Describe – then, explain

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

Coming to terms... of reference

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

The investigation model of last resort?

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

MORT: Method, Project, and Programme

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

Not quite ERIC

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...

Investigation tools

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...

Measurement can impair foresight

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...

Investigate your words

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

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