Module 1: Fundamentals of Incident Investigation

• What constitutes an incident vs an accident
• The purpose and benefits of investigation beyond blame
• Key steps in the investigation process: scoping, planning, evidence collection
• Principles of objectivity and preserving evidence
• Exercise: Review a past event in your organization (or a case study); outline an investigation plan identifying key questions and evidence to collect.

Module 2: Human Factors & System Thinking

• Human error vs systems failure: applying the Swiss Cheese Model
• Organizational and latent factors that contribute to incidents
• Models like SHELL (Software, Hardware, Environment, Liveware) for understanding human interaction
• Overcoming investigator bias and understanding cognitive limitations
• Case Study: Analyze a simple incident scenario using the Swiss Cheese Model or SHELL model, and identify latent conditions.

Module 3: Root Cause & Causal Analysis Techniques

• Root Cause Analysis (RCA) basics: what is it, why it matters
• Structured investigation tools: Cause andEffect (Ishikawa) diagrams, timelines, barrier analysis
• Introduction to systems based tools like AcciMap for multi-level causal mapping
• Prioritizing causes and formulating follow up actions
• Group Activity: In teams, build a simple AcciMap or fishbone diagram for a hypothetical incident, then propose corrective actions.

Module 4: Evidence Gathering & Interviewing

• Best practices for interviewing witnesses and gathering statements
• Documenting the scene: photos, measurements, logs, chain of custody
• Managing bias, preserving integrity, and ensuring completeness
• Working with limited or conflicting information
• Exercise: Role play investigator witness interviews to practice active listening, neutrality, and capturing relevant data.

Module 5: Reporting, Learning & Recommendations

• Structuring an investigation report: background, analysis, conclusions, recommendations
• Linking findings to organizational learning: near miss programs and feedback loops
• Communicating results: to leadership, workers, and stakeholders
• Designing corrective and preventive measures, tracking their implementation
• Capstone Project: Create a mock incident report, including root cause analysis and recommendations, plus a learning action plan for the organization.