After an accident or near miss, what matters is what your organisation takes away from it. Together with your team we rewind the event, understand why decisions made sense at the time, and make visible the conditions you can shape.
Incident investigation is the structured review of an accident, near miss or other event with the aim of learning from it. It is designed for HSE leads, management and project leaders. SAFETEE reconstructs why decisions made sense on site, identifies the conditions behind them and delivers a report, an action plan and a learning brief for your team.
Last updated:
Many investigations stop at the last action before the event. We look further back: at planning, time pressure, materials, information and coordination. That is where you find the levers that prevent similar events in future.
After an occupational accident, a near miss with high potential or an operational disruption. Also when events keep recurring or previous investigations no longer produce new insights.
A traceable report with the sequence of events and system causes, an action plan with clear owners and a learning brief your supervisors can use to discuss the event with their teams.
Every investigation follows the same path. Depth and pace depend on the severity of the event and on what your team needs.
Care and safety come first. We then record traces, photos, data and documents and talk to the people involved promptly, coordinated with your organisation and with the investigating bodies.
We reconstruct the sequence from the perspective of those involved: what did they see, know and weigh up? Actions that seem hard to understand in hindsight often made sense in the moment. That is where understanding begins.
We rewind further to planning, work orders, resources, interfaces and rules, separating what was decided on site from the conditions that shaped those decisions.
Actions target the conditions and come with an owner, a deadline and an effectiveness check. A learning brief carries the insights to other teams, shifts and projects.
“Why did it make sense at the time?” opens up an investigation, whereas looking for someone responsible tends to close it quickly. The idea comes from human factors research, for example by Sidney Dekker, and underpins approaches such as HOP and Safety-II. People speak more openly, and actions address the causes.
After serious accidents, the police, public prosecutor, occupational safety authority or statutory accident insurer often carry out their own investigations. Our investigation serves learning within your organisation and runs in coordination with these proceedings. Please clarify reporting duties and legal questions with your legal advisers; we provide the technical basis.
We carry out the investigation or support your team through it, from day one to the action plan.
The people who do the work and those who plan it describe together how the work actually gets done and where it can become safer.
For supervisors and HSE teams who lead investigations themselves. Practical, based on your own or anonymised cases, delivered in-house or soon through SAFETEE Academy.
We analyse your previous reports: how deep do the causes go, how effective were the actions, which patterns keep recurring?
We choose the method according to the event, its complexity and the people involved. Two approaches often complement each other, for example a learning team for the view from the field and a system analysis for the organisation.
Facilitated conversations between those who do the work and those who plan it, after an event or proactively. Popularised by Todd Conklin and the HOP movement.
Human and Organizational Performance assumes that people make mistakes, that context drives behaviour and that the way leaders respond matters. Its roots lie in the US nuclear industry.
Following Erik Hollnagel, you also learn from what goes right every day. We compare work as planned (work-as-imagined) with work as it is actually done (work-as-done).
Jens Rasmussen (1997) arranges influences across levels: from what happened on site through organisation and management to regulation. Well suited to complex events with many parties.
The Incident Cause Analysis Method builds on James Reason's model and groups factors into four categories: defences, actions, task and environmental conditions, and organisation.
Quick and intuitive, and helpful for simple sequences. For complex events a single causal chain oversimplifies (Card, 2017), so we add system analyses there.
Under section 193 of the Social Code VII, employers report an accident to the accident insurer if an insured person dies or cannot work for more than three days, within three days of learning of it. Fatal accidents and accidents with several injured people are reported immediately. Paper reports are accepted only until the end of 2027.
Source: section 193 SGB VII (version of 12 May 2026); BG ETEM “Unfall melden”, 20 July 2026; BGHW, 21 February 2024. Not legal advice.
“Human error” describes where an investigation stopped, not why the event happened. The German federal institute BAuA therefore aims its guide to investigating occupational accidents at underlying causes in the organisation. The 5 whys method also reduces complex sequences to a single chain. System causes show where actions really take effect.
Source: Fahlbruch/Meyer, BAuA, 2013; Card, BMJ Quality & Safety 26 (2017) 671–677; accessed 30 September 2026
Incident investigation is a module of our Safety Consulting. These services follow on from it:
Expert assessment of specific questions after an accident.
Clear rules at the interfaces with partner companies when events originate there.
Know, delegate and document your duties before anything happens.
An incident investigation is the structured review of an accident, near miss or operational disruption. It reconstructs the sequence of events, asks about the conditions behind the decisions of those involved and derives actions that prevent similar events in future. The aim is learning, not assigning responsibility.
An investigation for learning asks which conditions made the event possible. Liability and criminal responsibility are clarified by authorities, courts and your legal advisers. Keeping the two questions separate helps people report openly and leads to actions that address the actual causes.
A learning team is a facilitated conversation between the people who do a job and those who plan it. Together they describe how the work actually gets done, where the difficulties lie and what makes it safer. Learning teams work both after an event and proactively.
People usually act in the way that makes sense to them at the time, with the information, time and resources they have. Understanding that view reveals the conditions that can be changed: planning, tools, coordination or time pressure. This leads to actions that work for every team.
Under section 193 of the Social Code VII, accidents must be reported if an insured person dies or is unable to work for more than three days, within three days of the employer becoming aware. Fatal accidents and accidents with several injured people are reported immediately. Section 6 ArbSchG also requires you to record them. Please check individual cases with your legal advisers.
Yes, especially near misses with high potential for harm. They reveal the same conditions as an accident without anyone being injured, and those involved usually speak more openly. We recommend selecting by potential harm rather than by the number of reports.
As early as possible, once care and safety are ensured. Traces, data and memories are most complete in the first few days. After serious accidents we coordinate the start with your organisation and the investigating bodies.
Yes. In the training on investigating events, your supervisors and HSE teams learn interviewing, methods and action planning using your own cases. If you wish, we accompany the first investigations and review your reports until the process runs smoothly.
Event, date, people involved: with these details we can tell you how we can help, and we will get back to you promptly. We treat your information confidentially.
