Dr. Ayers walks through the step‑by‑step process of conducting an effective incident investigation. The episode reinforces that investigations must be systematic, timely, and focused on learning, not blame. Sources:
The first step is to ensure:
Injured employees receive care
The area is made safe
Hazards are controlled
Evidence is preserved
A delayed response leads to lost information. Sources:
Dr. Ayers emphasizes collecting:
Photos and videos
Equipment settings
Tools and materials involved
Environmental conditions
Physical evidence
This forms the factual foundation of the investigation. Sources:
Interviewing employees and witnesses quickly ensures:
More accurate recall
Better detail
Less influence from others
Interviews should be open‑ended and non‑blaming. Sources:
The episode stresses digging deeper than surface‑level explanations. Investigators must examine:
Behaviors
Conditions
System contributors
Organizational factors
This step prevents “worker error” from becoming the default conclusion. Sources:
Causal factors explain what happened. Root causes explain why it was possible. Dr. Ayers highlights the need to:
Ask “why” repeatedly
Look for system weaknesses
Avoid blame‑based reasoning Sources:
Corrective actions must:
Address root causes
Be realistic
Reduce or eliminate the hazard
Have clear ownership and deadlines
Weak corrective actions guarantee repeat incidents. Sources:
The investigation is not complete until:
Actions are implemented
Their effectiveness is confirmed
The risk is reduced
Lessons learned are shared
Verification closes the loop. Sources:
Investigations must be structured and timely.
Evidence and interviews form the backbone of accuracy.
Causal factors and root causes are not the same.
Corrective actions must be meaningful and verified.
The goal is learning and prevention, not blame.
