Context and local rationality
Every decision that looks wrong in hindsight made sense at the time, but standard methods rarely capture what the person knew, what pressures they faced, or what options they believed they had.
Your corrective actions are focused mainly on the worker?
The LFNW program finds the context, the error traps, and the organizational factors that set the failure up.
How do we improve incident investigations beyond root cause analysis?
Go beyond root cause analysis by investigating the context, the error traps, and the organizational factors that set the failure up. Things go wrong for the same reasons that things usually go right, so an incident is a window into how work normally happens. Corrective actions then target the conditions that made the failure likely.
Things go wrong for the same reason that things go right
Same conditions
Success
The adaptation works. Nobody notices.
Incident
The same adaptation does not work this time.
This is why the skills you need for investigating incidents are the same skills you need for learning from normal work.
What common accident investigation methods miss
Error traps and organizational factors
Confusing labels, outdated procedures, and tools that do not fit the task set someone up to fail, and they rarely appear in a cause-and-effect diagram.
Adaptations and workarounds
People adjust when procedures do not match the job, and when an adaptation does not work the investigation finds a violation instead of asking why the adaptation was necessary.
Dependencies between teams
The event at the workstation was often shaped by decisions made weeks earlier in planning, engineering, or scheduling, but standard methods stop at the person closest to the failure.
A different set of investigation skills
Addressing the gaps above requires a different set of skills: the ability to reconstruct context, identify error traps and organizational factors, manage cognitive biases during interviews, write findings that trigger empathy rather than blame, and hold accountability conversations that rebuild trust.
The training program below develops these skills at two levels of depth.
The training agenda
The content is organized across eight chapters, from foundations through evidence collection and analysis to accountability and strategy.
Foundations
The introductory program and the starting point for investigation capability. It builds a shared foundation across the core chapters.
Masterclass
The in-depth program for developing a broad range of skills and tools across every topic. Built for master investigators, central safety teams, and centers of excellence.
A sample of the topics covered
Reconstruct context
- How context drives behavior
- How dependencies create risk
- Constraint analysis
- Human error analysis
- Non-compliance analysis
Interview without bias
- Preventing fundamental attribution error
- Detecting lying and deception
- Investigating versus partnering for learning
Support people after the event
- Psychological effects of injury-related trauma
- Psychological first aid
- Supporting second victims
Write findings people accept
- Reframing judgmental language
- Writing a context-rich story
Hold accountability that rebuilds trust
- Introduction to restorative justice
- Trust recovery process
- Boundaries between investigation and accountability
Build the capability
- Identifying your investigation ecosystem
- Developing your capability structure
The full program, in one document
The full program breakdown, including the training agenda, the investigation ecosystem upgrade, and Marcin's credentials.
Download the brochure
What this means for your role
Senior leaders
Before
You respond with frustration after a serious event and your team filters what they tell you.
After
You lead with a caring response, ask how rather than who, and get the honest account you need to prevent the next one.
Safety and operations personnel (site-level investigations)
Before
Your corrective actions say "retrain" or "remind" and the same events keep recurring.
After
You identify the error traps that contributed, develop actions jointly with the people who do the work, and your recommendations actually get used.
Master investigators and central teams
Before
Your investigation produces a cause-and-effect diagram that explains the failure but misses the context that made every decision rational at the time.
After
You trace how different teams, resource constraints, and organizational factors contributed over time, and your report drives system-level change.
HR, legal, and support functions
Before
Your disciplinary process runs in parallel with the investigation and the two produce conflicting signals about accountability.
After
Your accountability framework is aligned with the investigation approach, so the process supports learning and trust recovery rather than undermining both.
Built by someone who led investigations at enterprise scale
This program was developed by Dr Marcin Nazaruk, who previously led human factors in investigations at BP. He is the author of IOGP Report 642 on Learning from Normal Work and has authored investigation-related guidance for the Energy Institute, HPOG, and SPE.
Marcin has redesigned investigation and learning processes for multiple global corporations across oil and gas, pharmaceuticals, and manufacturing. His work has been recognized with the SHP Trailblazer Award, the SPE International HSE Award, and the CIEHF President's Award.
We also help you upgrade the system around it
For the organization to learn differently, the system around the investigation needs to change as well.
We offer a guided process where your team updates seven areas of your investigation ecosystem.
Questions about the program
Most investigation training teaches a cause-and-effect method (5-Why, fishbone, TapRooT, ICAM). These methods work well for equipment failures. This program teaches the additional skills needed to investigate human and organizational behavior: understanding context, identifying error traps, tracing dependencies, managing bias, and writing reports that produce system-level recommendations rather than blame.
No. The program integrates with your existing process. If you use TapRooT, ICAM, or another method, the new skills and tools sit alongside what you already do. Chapter 8 specifically focuses on updating your existing investigation ecosystem rather than replacing it.
When someone is involved in an incident, the way the organization responds determines whether that person and their colleagues will report openly in the future. Punitive responses reduce reporting. Restorative approaches hold people accountable while rebuilding trust and maintaining engagement. This is a practical concern: if your investigation process produces blame, people stop sharing the information you need to prevent the next event.
The person involved in a serious incident often experiences significant psychological distress, including guilt, shame, and trauma symptoms. Many organizations focus entirely on the physical casualties and the investigation process, overlooking the wellbeing of the person whose actions are being scrutinized. The program covers how to recognize and support second victims as part of the incident response.
The 2-day Foundations is designed for site-level investigators and operations managers who need core skills. The 5-day Masterclass is designed for master investigators, central safety teams, centers of excellence, and anyone responsible for designing or overseeing the organization's investigation process. Leaders attend the Mindset Shifter session, which can be delivered as a standalone or as part of either program.
Pricing depends on group size and delivery format. Minimum group of 10, with the per-person cost decreasing for larger groups. Delivered in person or online. We accept GBP, USD, and EUR.
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