Using incident analysis to tighten up systems

Using Incident Analysis to Tighten Up Systems… NOT Blame Employees

By Josh Williams, Ph.D.

The way in which incident analyses are handled in organizations has a significant impact on organizational culture. In fact, effective incident analysis practices are significantly related to fewer incidents and injuries.1 In healthy organizations, incident analyses are used to get considerable field input into the factors associated with the incident and help leaders understand and analyze system factors contributing to incidents. This reinforces a learning environment to prevent similar incidents in the future and helps avoid typical “blame and train” perceptions following injuries.

Leaders should follow these guidelines to create robust incident analysis processes:  

  • Ensure system factors are primarily considered following incidents (instead of simply labeling the incident as operator error with the corrective action of retraining)
  • Drive fear and excessive paperwork out of the process as much as possible
  • Make sure hourly employees are included on cross-sectional teams analyzing incidents
  • Use punishment sparingly and reserve it for cardinal rule violations, willful negligence, or multiple (repeat) offenses
  • Avoid viewing incidents in isolation without application to other jobs or locations
  • Make improvements based on the results and share lessons learned across the organization

Conscientious leaders are understandably upset when injuries occur, especially when considerable time has been put into providing training, tools, procedures, and PPE to do the job safely. It’s important to resist the temptation to ask why people ‘messed up’ and take a more thorough, systems approach to better understand the situation. In some instances, operator error is the primary reason for an incident. However, in the vast majority of cases there are other system factors (communication gaps, excessive time pressure, insufficient personnel) contributing to the incident. It’s critical that leaders uncover these issues, make necessary fixes, and share these changes with all employees.

Improving incident analysis helps prevent future injuries. It also boosts safety culture and morale because employees feel like part of the solution instead of being blamed.  

At Propulo, we help leaders better understand and manage incident analyses to promote a healthier organizational safety culture and prevent future injuries.


  1. Wachter, J. & Yorio, P. (2014). A system of safety management practices and worker engagement for reducing and preventing accidents: An empirical and theoretical investigation. Accident Analysis Prevention, 68 (117-30).

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