Incident investigations – what are we really trying to learn?

Mike Pennefather • 28 November 2024

We’re always told to investigate any incidents, including near misses. The Safety Management System Requirements for Adventure Activity Operators requires every operator to “establish a process for investigating and reviewing incidents, understanding the underlying causes, identifying improvements to the SMS, and analysing trends.” This is so that we can learn from events and don’t miss out on a valuable opportunity to improve.


I had a great chat with an app developer who has designed an app for farmers. Her business gets regular complaints that the font is hard to read, the buttons are too small and the app is too complicated to use. Now it would be easy to simply say that the farmer’s phone is the size that it is and there’s nothing that can be done about that. Or that the farmer has thick fingers from a lifetime of hard work so his fingers aren’t designed for smartphones. But saying “it is what it is” doesn’t improve the situation; the farmer goes away unhappy and the company loses a client. Instead, they acknowledge that it is the farmer’s lack of ability to use their phone properly BUT what can they do to improve their system to make it easier? What can they do to reduce the likelihood of mistakes and frustration from inexperienced app users? Investigating the complaints to identify what can be done to reduce this identified human error keeps their customers happy and reduces the likelihood of more farmers having the same issues. This increases their customer base.


In Adventure Activity incidents, we’ve seen that ‘human error’ is often listed as the underlying cause. But what led to that human error? What allowed human error to occur? Could it happen again? What could we change to reduce the likelihood of that same error being made by another customer? Asking questions like these could really help to improve our systems to reduce the chance of people being able to make avoidable mistakes. We’re all human, and we all make mistakes. What can we put in place in our activities to make sure that when we do make a mistake, it doesn’t have terrible consequences? 


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