Development of a Senior Investigator Training program for a leading energy group in Northern Europe


While forensic investigation and establishment of technical cause – effect relationships is usually well understood and handled adequately, incident Investigations are struggling to integrate the human and organisational factors into causal analysis. The tendency is to focus on nearby factors, factors that where close in time and space to the actual incident. In many cases the investigation stops when a Human Error has been found and named according to some taxonomy. This is considered as a reasonable explanation for the underlying causes to the accident/incident. However, it is becoming more and more evident that other factors play a major role in system failures. It is recognized that practitioners do not act in isolation, or in a vacuum, but rather in an interaction with many other parts of the sociotechnical system.

Hindsight bias leads us to see only those forks in the road that practitioners decided to take— not the multiple alternatives exposed to the practitioners along the road, many equally meaningful and rational to the practitioner in the situation. Therefore, in this training program the participants will train themselves to reconstruct the situation that people found themselves in when the situation evolved around them.

Our Approach

The Investigator Human Factors training program is based on safety models provided by Hollnagel, Dekker and Woods. These safety models are founded on theories based on system thinking, complexity, resilience engineering and control theory. In these models Human Error is considered as an indication of problems deeper in the organisation, and therefor requiring a different approach when completing incident investigations. Ultimately, this approach will increase return of investment associated with incident investigations. The training will enable the investigators to move beyond human shortcomings and instead identifying systemic factors in the organisation.

This course provides theoretical and practical knowledge to enable the course participants to identify how aspects of the organisation, documentation, operational or managerial decision-making, or industry standards may all have influenced to what people at the sharp-end saw as making sense at the time. The two-day course contains elements such as human and organisational factors, accident models, interview techniques and a practical case study in order to apply the newly acquired investigation skills. In addition, and throughout the course, case studies are utilized to exemplify and provide clear examples of the theory presented in the training program. This part is always tailored to client needs.

In addition, the training program can be integrated with any incident investigation method applied such as Kelvin TOP-SET, Tripod Beta etc.


To better understand the strengths and weaknesses of the sociotechnical system, instead of pointing to individual failures or shortcomings. This is the only way to systematically make any system safer and ultimately making sure the organisation can improve its productivity.