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The ‘traditional’ approach to incident investigation, almost exclusively focuses on the individual or behavioural contribution to an incident and largely ignores, or downgrades, other potential contributory factors. The emphasis in this type of investigation is on the person or persons involved, identifying their contribution to the incident and highlighting only those immediate causes that are obviously and unambiguously implicated.

Once these conditions are satisfied, the investigation is typically seen as complete. Underlying causes, such as poor procedures, inadequate equipment, that may have influenced behaviour or led to unsafe conditions are rarely formally identified and captured in this type of investigation. There are a number of fundamental problems with this approach.

These include: a tendency to focus on ‘what’ and ‘how’ rather than ‘why’ the incident occurred, to restrict the investigation to a limited set of causes, to focus prevention on disciplinary or procedural approaches and to assign responsibility and blame to those most immediately involved. Lastly, this approach tends to lead to short term, and ultimately ineffective, interventions since the underlying conditions that may create vulnerability to a wider range of incidents remain un-addressed.