Embedding Investigation Thinking into Everyday Work

Introduction

Most organisations view incident investigations as a reactive process—something triggered only when something goes wrong. However, the most mature safety cultures recognise that investigative thinking is not just a response to failure; it’s a proactive mindset. Embedding investigation thinking into everyday work empowers employees to continuously seek improvement, identify weak signals, and prevent issues before they escalate.

Shifting the investigation from a post-event tool to an everyday mindset is a critical step in building resilient systems and safer workplaces. In this article, we explore what investigation thinking really is, how to embed it into daily activities, and the benefits organisations can expect from making this shift.

What Is Investigation Thinking?

Investigation thinking is the application of investigation principles—such as curiosity, systems thinking, and evidence-based decision-making—to everyday work activities. It involves:

• Questioning why things are done a certain way

• Seeking to understand the broader context of actions and outcomes

• Recognising early warning signs and weak signals

• Applying tools like root cause analysis or the PEEPO framework preemptively

• Considering human and organisational factors in all decision-making

Unlike formal investigations, this type of thinking doesn’t require a full incident to occur. It thrives on daily observations, informal conversations, near-miss reviews, and process walkthroughs.

Why Embed Investigation Thinking?

Many incidents that result in injury, financial loss, or reputational damage are preceded by smaller failures—often unnoticed or normalized. By embedding investigation thinking into routine work, organisations can:

• Identify latent conditions before they manifest into serious events

• Foster a learning culture rather than a blame culture

• Encourage continuous improvement

• Empower employees at all levels to be part of the safety solution

• Reduce the frequency and severity of incidents

This shift helps transition safety from compliance-focused to insight-driven.

Key Principles for Embedding Investigation Thinking

To successfully embed this mindset, organisations need to operationalise several key principles:

1. Curiosity Over Compliance

Encourage employees to ask "Why?" not just "What went wrong?" This is about nurturing curiosity at all levels. Managers should role model this by asking questions like:

• “What makes this task prone to error?”

• “Are we relying too much on human intervention?”

• “Is there a better way to design this system?”

Curiosity drives insight and improvement far better than checklists alone.

2. Normalise Learning From Success and Failure

Investigation shouldn’t only happen after negative events. Learning from things that go well—especially when they went well despite challenges—offers equally valuable insights.

This is often called "Safety-II thinking": focusing on what makes things go right. For example, when a team narrowly avoids a failure due to improvisation or workarounds, it’s worth asking:

• Why was a workaround needed?

• What does this say about our standard procedures?

• Could this workaround become normalized and introduce risk?

3. Apply Frameworks Lightly and Often

Tools like ICAM, TapRooT, and 5-Whys are often associated with major investigations, but elements of these frameworks can be used informally.

Encourage team leaders to apply simplified tools during toolbox talks, pre-start meetings, or after minor deviations from planned work. This builds fluency and familiarity with investigation tools without the formality.

For instance, an ICAM-style look at a near-miss might ask:

• What was the immediate action?

• What task/environmental factors contributed?

• What organisational conditions played a role?

This doesn't need a formal report—just good discussion and shared understanding.

4. Strengthen Psychological Safety

Employees must feel safe to raise concerns, admit mistakes, and explore failures without fear of retribution. Without psychological safety, investigation thinking is stifled.

Leaders should:

• Respond to concerns with appreciation, not criticism

• Avoid knee-jerk blame and punishment

• Encourage the sharing of lessons learned, even from minor issues

• Involve teams in collaborative analysis rather than top-down reviews

Embedding Into Daily Activities

So, how can organisations make investigation thinking part of the everyday fabric of work?

1. Daily Operational Reviews

Include a “What did we learn today?” moment in shift handovers or daily huddles. Encourage discussion of near-misses, unexpected events, or positive adaptations.

2. Pre-Start Checks and Job Planning

Use investigation tools in forward-looking ways. During task planning:

• Anticipate potential failure points

• Discuss previous learnings from similar tasks

• Explore how human error or environmental factors could impact success

This proactive lens helps teams work more safely and efficiently.

3. After-Action Reviews (AARs)

Make AARs routine after projects, jobs, or campaigns—whether successful or not. Structure them with investigation questions:

• What happened?

• What was expected to happen?

• Why were there differences?

• What can we learn?

This builds investigative capacity across the organisation.

Building Investigation Capability

Embedding investigation thinking isn’t just about adding new activities—it requires capability building at all levels:

1. Train Supervisors and Team Leaders

Equip them with the skills to identify weak signals, conduct informal investigations, and guide their teams in thinking systemically.

Training should cover:

• Human error and systems thinking

• Asking effective questions

• Conducting informal reviews

• Sharing learnings constructively

2. Use Real Examples for Practice

Build familiarity with investigation tools using real workplace examples—not just hypothetical ones. Practice analyzing near-misses, ambiguous cases, and even successful recoveries.

3. Make It Visible

Celebrate when investigation thinking leads to improvement. Use dashboards, whiteboards, or digital platforms to share small wins and lessons learned. This keeps the process alive and shows its impact.

The Benefits of an Investigative Culture

Organisations that embed investigation thinking see clear benefits:

• Reduced incident frequency and severity

• Greater employee engagement in safety and improvement

• Better decision-making across all levels

• Increased resilience through early identification of system weaknesses

• Faster learning cycles from both success and failure

Most importantly, it supports a culture where learning and accountability go hand-in-hand—without blame.

Conclusion

Investigation thinking belongs in every workplace—not as a reaction to catastrophe, but as a proactive daily discipline. By making investigation principles part of the everyday routine, organisations foster a culture of curiosity, learning, and continuous improvement.

Whether you're on a factory floor, in a control room, or at a project site, every task is an opportunity to ask, “How could this go wrong?” and “What keeps it going right?”

When investigation thinking becomes habitual, safety becomes resilient—not just in procedures, but in the people who carry them out.