Behaviour-Based Incident Analysis (Accident
and effective analyses of workplace incidents
are critical components of a comprehensive
safety management system. Yet, many Incident
Analysis processes (i.e., accident
investigations) fall short. They frequently fail
to identify and resolve the real root causes of
injuries, process incidents, and near misses.
Because the true root causes of incidents are
within the system, the system must change to
prevent the incident from happening again.
Further, because employees’ perceptions of
incident analyses are often negative,
individuals are often reluctant to report
incidents and participate in the analysis for
fear of reprisal or because they believe little
improvement will result. How do we get the
information we need? Why don’t employees report?
How do we get employees to openly participate in
the analysis process?
While one goal of an incident analysis process
is to determine the immediate causes and root
causes that allowed the incident to occur (so
effective countermeasures can be taken to reduce
future injury risk), there’s a second, equally
important goal. The incident analysis process
must also encourage full and open participation
of employees by eliminating a fault-finding
adversarial atmosphere so often surrounding the
process. Organisations must let go of outdated
ideas on how to deal with mistakes caused by
human error and calculated risks. Dutcher SMS
teaches organisations how to reach both goals.
In particular, Dutcher SMS
teaches organisations how to identify system
influences on risky behaviour and human error
and how to involve employees in conducting an
open and honest exchange of information
How can Dutcher SMS
these concerns, Dutcher SMS
offers three levels of service:
conducts a four-step analysis and redesign
of the organization’s incident analysis
process followed by training and evaluation.
conducts a two-day workshop for both
experienced and novice participants familiar
with basic incident analysis procedures.
conducts a one-day workshop which is a
reduced version of the two-day workshop.
Behaviour-Based Incident Analysis: Full Redesign
assists organisations assess, modify, and
evaluate their incident analysis process. The
typical approach involves four steps:
Situation Appraisal and
Planning. Dutcher SMS
personnel gather background data concerning
the current incident analysis process.
This includes reviewing documentation as
well as surveying and/or interviewing
Based on the information gathered
in Step 1, Dutcher SMS
works with site personnel to develop revised
investigation procedures and tools. The
new process is documented in a “guidebook”
for use by the incident analysis teams.
training course is customised and delivered
for prospective members of the
organisation’s analysis teams. This course
is typically a two-day course similar to the
one described in Level Two Support: Two
Process Implementation and
Follow-Up Coaching. During the
early stages of implementation, Dutcher SMS
will review the results
of 2-3 analyses to provide feedback on the
use of the new processes and tools.
Following each analysis, Dutcher SMS
will administer a short survey soliciting
feedback from the participants. After 6-12
months, Dutcher SMS
will repeat the survey/interview process
conducted in Step One.
Behaviour-Based Incident Analysis: Two Day
two-day workshop is designed for both
experienced and novice participants familiar
with basic incident analysis procedures. In this
workshop, participants learn to go beyond the
conclusion that the incident resulted from
simple human error. Instead, they learn how to
identify the root causes of human performance
deficiencies enabling them to reduce
systematically the motivation for risk taking
behaviour and the varied causes of human error.
Through the use of case studies and hands-on
exercises, participants apply an investigation
philosophy of “fix the system” not “blame the
This is not a "how-to" course on traditional
incident analysis skills such as physical
evidence collection and preservation or use of
analytical tools (e.g., cause and effect
diagramming, multi-linear event sequencing, or
Management Oversight Risk Tree). Rather, this
two-day workshop provides an in-depth look at
how employees’ performance and safety-related
behaviour is influenced by the organisational
culture and the physical work environment.
Specifically, participants will learn:
Practical applications of theories of human
motivation, human information processing and
human error to incident analysis and
development of appropriate countermeasures.
human behaviour is influenced by management
systems including training, supervision,
organisational reward structures, and
technology, including human-machine
interface design and the design and use of
operating procedures, influences human
identify and prevent repeated human error or
work environments encourages risk-taking
behaviours in the workplace.
Witness interviewing techniques to foster
disclosure and enhance memory of events.
After attending the workshop, participants will
be able to:
Conduct incident analyses to better identify
not only immediate causes but multiple root
causes including organisational system
failures and human performance deficiencies.
Develop and implement effective
countermeasures to prevent future incidents.
an environment of fact finding to encourage
employee participation in incident
reporting, analyses, and remediation.
Two-Day Workshop Manual and Suggested Reading
Incident Reporting and Analysis Process: One Day
conducts a one-day workshop which is a reduced
version of the two-day workshop. Often the
senior managers attend the two-day version and
then the one-day is provided for front line
supervisors and others participating more
directly in the analyses process.
To review the two day course content, see
Two Day Workshop