How to Handle a Workplace Incident Investigation That Exposes Management Decisions

Workplace incident investigations are intended to uncover the facts, understand causal factors, and identify systemic issues — not to assign blame. But what happens when the facts point to decisions made by management as key contributors to the incident?

Whether it’s a cost-cutting directive, inadequate resourcing, poor change management, or conflicting priorities, management decisions are not immune from scrutiny. This can be deeply uncomfortable, politically sensitive, and risky — especially if not handled with transparency, fairness, and procedural rigour.

This article offers a step-by-step framework for investigating workplace incidents that implicate management while maintaining organisational integrity, employee trust, and legal defensibility.

1. Acknowledge the Complexity of Management Failures

Incidents are rarely caused by a single factor. When management decisions are part of the causal chain, they usually relate to:

• Resource allocation (staffing, equipment, time)

• Priority-setting (production over safety)

• Policy or procedural changes without appropriate consultation or risk assessment

• Failures in Strategic Oversight

• Culture-driven risk normalisation ("we’ve always done it this way")

These are systemic contributors, not character flaws. But if investigations are poorly handled, these decisions may be framed as incompetence or negligence, triggering defensiveness and blame-shifting.

Instead of focusing on “Who made the decision?” focus on “What context led to this decision being reasonable at the time?”

2. Establish Psychological Safety — Even for Leaders

Most organisations emphasise psychological safety for front-line workers. However, during high-stakes investigations, managers may fear reputational damage, job loss, or disciplinary action if their decisions are examined.

This fear can:

• Derail cooperation

• Trigger legal resistance

• Undermine transparency

Investigators must create a space where managers feel safe to discuss difficult trade-offs they faced at the time.

Language matters here. Replace:

• ❌ “Who authorised this budget cut?”

• ✅ “Can you help us understand the constraints at the time?”

This helps distinguish between intentional neglect and constrained decision-making — two very different things with very different implications.

3. Ensure Independence and Neutrality of the Investigation Team

To credibly investigate decisions made by senior leaders, the investigation must be:

• Independent: Not led by internal staff who report to implicated managers

• Neutral: Focused on facts and systems, not personalities or reputations

• Structured: Using a consistent methodology like ICAM, which includes Organisational Factors

Where possible, consider external facilitators or investigators when:

• The decisions under review were made by executives

• There is high potential for conflict of interest

• The organisation wants legal privilege over findings (via external legal counsel)

4. Use a Structured, Systems-Based Methodology

Frameworks like ICAM (Incident Cause Analysis Method) help shift the narrative from “Who’s at fault?” to “What conditions allowed this to occur?”

ICAM investigates:

• Immediate causes (unsafe acts, failures)

• Contributing factors (training gaps, supervision)

• Workplace conditions (equipment, procedures)

• Organisational factors (resourcing, culture, leadership decisions)

This layered approach allows management decisions to be examined in context — not in isolation — and avoids oversimplified or blame-heavy findings.

Example:

A decision to reduce maintenance frequency led to equipment failure. 

The ICAM investigation shows this decision was made due to:

• Budget constraints

• Assumptions about risk tolerance

• Historical performance data that did not reflect actual equipment degradation rates

The decision is a factor, but the conditions enabling that decision are the true learning points.

5. Treat Executives Like Everyone Else — But With Sensitivity

Executives must be treated with the same fairness and transparency as any other staff. That includes:

• Being interviewed (with appropriate scheduling, tone, and framing)

• Having access to the scope and methodology

• Being informed of the process and findings timeline

Avoid language that implies targeting:

• ❌ “We need to know why you approved this.”

• ✅ “We’d like to understand the broader decision-making process around X.”

Also, ensure they’re aware of:

• Their right to representation

• The confidentiality of the process

• How findings will be communicated and used

Many executives are willing to be transparent if they trust the integrity and intent of the investigation.

6. Manage Legal and Industrial Relations Risks

When management decisions are part of the causal chain, there may be exposure to:

• Regulatory action (e.g. breaches of WHS duties)

• Legal liability (especially under officer due diligence provisions)

• Reputational damage

• Shareholder scrutiny (in listed companies)

• Union involvement or workforce backlash

To mitigate these:

• Consult legal counsel early, especially around possible breaches of WHS laws or officer duties

• Consider Legal Professional Privilege (LPP) if findings may be legally sensitive

• Be transparent but careful in internal communications — avoid prejudging or oversharing

• Engage unions proactively if decisions affect working conditions

Don’t hide or downplay uncomfortable findings. But don’t jump to disciplinary actions without legal advice either.

7. Communicate Findings with Integrity

How you communicate the findings of a politically sensitive investigation can make or break trust.

Good practices include:

• Clear structure: Findings, contributing factors, lessons learned, actions

• Non-blaming language: Focus on systems, decisions, processes

• Balanced tone: Acknowledge difficult trade-offs or competing pressures

• Action focus: What’s being done to improve? What’s being changed?

Example phrasing:

"The investigation identified that several cost-saving initiatives introduced in Q2 2024 contributed to the unavailability of critical PPE. These decisions were made under significant financial constraints and in the absence of updated risk assessments. Moving forward, all budgetary changes affecting safety equipment will require formal hazard review and workforce consultation."

Avoid phrasing like:

• ❌ “Management failed to consider safety.”

• ❌ “This was a reckless decision.”

These statements may feel satisfying but often hinder learning and drive defensiveness.

8. Focus on Organisational Learning, Not Accountability Alone

It's tempting to use findings to “hold people accountable,” especially when harm has occurred. However, true safety maturity focuses on organisational learning.

Instead of:

"Who needs to be punished?"

Ask:

"What allowed this decision to be made and go unchallenged?"

Real learning means:

• Identifying gaps in risk communication up and down the hierarchy

• Recognising when production pressure overrides safety

• Redesigning decision-making frameworks to incorporate operational realities

• Building systems that flag unintended consequences early

Leaders should be involved in the learning process — not excluded from it. Invite them into workshops, retrospectives, and action planning sessions.

9. Support Managers Through the Aftermath

Even well-intentioned investigations can leave managers feeling exposed, ashamed, or alienated. This is especially true if their decision contributed to serious harm or loss of life.

Support might include:

• Coaching or mentoring

• Peer debriefing

• Formal performance review (with support, not punishment)

• Leadership development focused on risk-informed decision-making

Shame is a terrible teacher. Compassion and accountability can coexist — and create conditions for growth.

10. Use the Findings to Improve Leadership Systems

Finally, leverage the findings to build better leadership systems. That includes:

• Embedding safety into strategic planning

• Requiring formal risk review before key decisions

• Training managers in consequence scanning and scenario planning

• Establishing checks and balances (e.g. safety sign-off on budget cuts)

• Creating channels for dissenting voices to raise concerns

If a single management decision had significant negative consequences, ask:

• Were there early warning signs?

• Could someone have spoken up — and if so, why didn’t they?

• What governance structures need to change?

True leadership accountability isn’t about blame — it’s about building systems where good decisions are easier to make.

Closing Thoughts

Investigating incidents that implicate management isn’t easy. It can stir fear, resistance, and organisational tension.

But when done well — with independence, fairness, and a systems lens — these investigations are powerful catalysts for change. They shine a light on decision-making frameworks, challenge outdated assumptions, and build safer, smarter organisations.

It’s not about putting heads on spikes. It’s about putting learning above blame, and building a culture where even the highest levels of leadership are open to growth.

In the end, your credibility is defined not by whether you find fault, but by how you frame the story — and what your organisation chooses to do next.