Why Most Incident Investigations Stop Too Soon | Risk Matrix Episode 148
Risk Matrix #148: Why Most Incident Investigations Stop Too Soon
“The best investigations are the ones you have to run less often because a strong pre-incident risk assessment already caught the problem first.”
What is the myth of zero risk in safety management?
Most safety leaders say their goal is zero incidents. It is a noble aspiration. It is also, in practice, economically unfeasible.
Most investigations close the file on the direct cause because it is easy to identify and easy to move on from. That is also why incidents repeat. In this episode Dr. Logan F. Martin and James Junkin discuss Dr. Martin’s July 4, 2026 article “Untangling Direct, Underlying, and Root Causes After a Workplace Incident” and why stopping at the proximate cause is one of the most expensive mistakes a safety management system can make.
KEY TAKEAWAYS
- The trap of the obvious is the enemy of true root cause analysis. Billions have been spent on retraining workers yet serious injury and fatality trends have not significantly improved. Retraining addresses the direct cause, not the underlying management system failures that allowed the incident to happen in the first place. The corrective action that closes the file is rarely the corrective action that prevents the next incident.
- Incident investigation and risk assessment are two ends of the same rope. Dr. Martin asked James how many fatality investigations he had seen with a truly good job hazard analysis in place. His answer: not one. When investigation and risk assessment are disconnected, organizations identify what happened but never fix the conditions that made it possible.
- Organizations do not have memories. People do. James references the BP Texas City 2005 explosion and the Deepwater Horizon 2010 disaster. The Chemical Safety Board found the same underlying organizational culture problems present in both events, five years apart. When people leave, the memory of why a corrective action exists fades with them. That is how repeat incidents happen.
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