Written by Consultant Sam Hudson and Senior Consultant Pete Hibbert
Failure has long been burdened with stigma. When things go wrong, particularly in high-stakes environments such as aviation, the instinctive response has often been to locate the fault, assign blame, and remove the perceived source. This tendency is especially pronounced when human error is involved. Yet replacing one individual with another, without a genuine understanding of how and why an event occurred, does little to improve safety. Often, it merely disguises underlying weaknesses and creates the conditions for the same failure to occur again.
Turning Incidents into Lesson
Aviation safety relies not only on advanced technology and regulatory compliance, but also on how effectively organisations learn from adverse events and, crucially, apply those lessons. At the heart of this learning process lies the occurrence investigation. For it to be effective, the investigation must be actively supported by the organisation through clear leadership, adequate resources, and a culture that values learning over blame. Without that commitment, even the most thorough investigation risks becoming an academic exercise rather than a driver of meaningful safety improvement.
But how effective are these investigations in practice? Are organisations truly learning from them, or simply recording events? Are they digging deeply enough to uncover root causes rather than settling for convenient explanations? And perhaps most importantly, are the right people being selected as investigators, and then equipped with the skills, mindset, and resources required to carry out the task thoroughly and credibly?
Effective occurrence investigation rests on two essential pillars. The first is a Just Culture, one that encourages open and honest reporting and actively supports engagement with error management practices, including occurrence investigation. The second is the availability of well-trained, prepared, and properly resourced occurrence investigators. This piece focuses on the latter, recognising that even the strongest reporting culture will fall short without investigators who are capable of turning information into meaningful learning.
ICAO Annex 13 provides very clear standards to which incident investigations should strive to achieve (For the purposes of this paper, the term occurrence will be used in place of incident). Predominantly it is about understanding not just what happened, but exactly why an event occurred with a focus on preventing future reoccurrence through effective and sustainable interventions. On paper, this appears to be a straightforward task. The reality however can be anything but straightforward, especially where human involvement is concerned.
Enter The Investigator
Human-centric investigations conducted within an effective Just Culture require far more than the reconstruction of a linear chain of events. They demand a nuanced understanding of the conditions, influences, and everyday activities that shape both individual and organisational behaviour, and that gradually create a pathway along which an event moves from a latent possibility to a sudden, and sometimes hazardous, reality.
Achieving this level of understanding depends on access to candid, detailed insights from those closest to the occurrence. Interviews, therefore, are not a procedural formality but a critical investigative tool, enabling the exploration of motivations, perspectives, and mindsets that cannot be captured through documentation or timelines alone. In this context, the occurrence investigator is not merely a fact-finder, but a skilled interpreter of human behaviour and organisational dynamics.
Effective investigators do more than gather data; they uncover and articulate context. They seek to understand how and why decisions were made, what pressures and constraints were present, and how people and systems interacted in the period leading up to the event. Crucially, they must be able to analyse and communicate these insights clearly, so that others can understand not only what happened, but why it made sense to those involved at the time.
The Art of the Interview: Building Trust and Gaining Insight
Interviews are an integral part of any meaningful investigation and, wherever possible, should be used to inform the investigative process. They provide the investigator with the human context that data alone cannot offer. However, they are also delicate. For many individuals, being interviewed about a safety occurrence can be intimidating. If not handled correctly, this discomfort can lead to guarded responses, incomplete information, or even mistrust.
That is why the conditions under which interviews are conducted matter so much. Investigators must create a safe and respectful environment, one that aligns with the principles of a Just Culture. This means approaching interviews with empathy, curiosity, and professionalism, and certainly not with judgement or suspicion.
Those conducting interviews as part of safety occurrence investigations must also be carefully selected. They require strong communication and interpersonal skills, an investigative mindset, and a disciplined approach. They must be trustworthy, diligent, and capable of analysing and articulating complex findings without bias, speculation, or assumption. In short, they must be prepared for this crucial task not only technically, but also emotionally and intellectually.
So, How Prepared Are Your Investigators?
Given the complexity and importance of the investigator’s role, it is worth asking how well prepared your investigators really are. Do they have the skills to conduct thorough and methodical investigations? Can they navigate sensitive interviews with confidence and care? Are they able to analyse behavioural and organisational factors, including decisions and influences at management level, and design interventions that are effective and sustainable? If the answer to any of these questions is not yes, then it is time to invest in their development.
At Baines Simmons we understand the critical role investigators play in organisations. That’s why we’ve developed our Practical Skills for Investigators course; a hands-on, interactive designed to build capability.
This course goes beyond theory. It introduces structured techniques for analysing investigation data, conducting effective interviews and identifying the behaviours that contributed to occurrences. It also explores how to design sustainable interventions that reduce the likelihood of recurrence. Throughout the course participants apply these skills in practical scenarios, building confidence and competence in a supportive learning environment.
Professional Growth, Organisational Resillience
The benefits of effective occurrence investigations extend far beyond compliance. For organisations, they lead to safer operations, stronger systems with fewer repeat occurrences and a more resilient safety culture. For individuals, they offer a unique opportunity for professional growth.
Investigators play a pivotal role in shaping safety outcomes. Their work can lead to meaningful improvements, not just in procedures and policies, but in how people think about and engage with safety. By participating in investigations, individuals contribute directly to creating safer, more thoughtful and more adaptive systems. Being an occurrence investigator is not just a technical role; it’s a leadership role. And it deserves to be recognised, supported and developed accordingly.
Elevating Standards
As you reflect on your organisation’s approach to safety, it is worth considering whether your investigators are adequately prepared to meet this challenge. Are they equipped to uncover not only what happened, but why it happened, and to contribute meaningfully to preventing recurrence? Investment in investigator competence should be seen as a necessary part of a mature safety system. Ultimately, the effectiveness of an organisation’s investigations plays a significant role in the strength of its overall safety performance.
How Baines Simmons can help
At Baines Simmons we’ve developed tools, models and training courses that empower investigators to go beyond surface-level analysis and uncover the deeper systemic and behavioural factors that contribute to safety occurrences.
One of our key frameworks is the Flowchart Analysis of Investigative Results (FAiR). FAiR helps investigations move beyond blame and instead focus on understanding the context surrounding decisions and actions. However, to be applied effectively, FAiR relies on the quality of the underlying investigation. When supported by a well-conducted, non-judgemental, evidence-based investigation, FAiR enables organisations to apply a consistent and structured approach that aligns with Just Culture principles and supports the identification of meaningful, sustainable safety improvements.
To support the development of investigator capability, we also offer two specialised training courses:
Practical Skills for Investigators (Multi-Environment) - This course builds core investigative skills including interviewing techniques, behavioural analysis, and intervention design.
Practical Skills for Investigators (MEDA) - Tailored for those using Boeing’s Maintenance Error Decision Aid (MEDA), this course enhances investigators’ ability to apply MEDA principles effectively while integrating human factors and Just Culture thinking.
Both courses are highly interactive and scenario-based, equipping participants with practical, transferable skills that enable them to conduct more effective investigations and drive tangible safety improvements within their organisations.
To find out more, speak to our safety experts at hello@bainessimmons.com.