Why ‘failure to follow procedure’ teaches you nothing
Hosted by myosh, this webinar examined a common weakness in incident investigations: too often, the outcome is simply “the worker failed to follow procedure,” followed by retraining or a warning, with little real learning gained.
Mark Alston of Investigations Differently shared a better approach for minor and medium-harm events, using Event Insights to shift attention away from blame and toward the conditions that shape work.
The session argued that procedures usually describe the “good day,” not the messy reality of work, so a failure to follow procedure is a symptom rather than the cause. Instead of relying on tick-box investigation templates or a narrow root-cause mindset, Event Insights uses seven conversational questions to uncover what happened, what surprised people, what could have made the event worse, and what workers need in order to do the job well.
The value of the approach lies in the conversation it creates. By asking what helps on a good day, what frustrates workers, and what management may not understand, investigators can identify practical improvements that genuinely reduce risk. The message was clear: if organisations want better outcomes, they need investigations that learn from work as it actually happens, not just from what the procedure says should happen.
Click on this link to go to the Webinar.