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Opinion: incident investigations should shake down safety systems, not trigger trauma
When things go wrong, how do we ensure workers are not re-traumatised?
Professor Anjum Naweed
05 September 2024
Workers in high-risk industries are right to fear accidents – it's what helps prevent them. But fear of safety incident investigations can have the opposite effect. CQUniversity human factors and safety scientist Professor Anjum Naweed explains.
In Australia's safety-critical industries like resources, transport and health care, millions of dedicated people go to work with the real risk of not coming home.
Understandably, people begin their day with accidents in mind – attending toolboxes, doing risk assessments, examining safety notices, completing safety logs.
It's a healthy process (and often one required by legislation) to manage safety and prevent catastrophe.
But if something goes wrong, should workers end their day fearing investigation?
Research and industry reporting consistently finds human factors account for more than 90% of industry safety breaches.
I don't like the term "operator error." But try a Google News search for it, and you'll find countless accident investigations, blaming "operator error" for everything from oil spills, to amusement ride crashes, to train doors closing on passengers.
A 2008 study of Queensland mining safety made headlines when "operator error" was identified to be a contributing factor in 95% of all incidents.
Those numbers and stories stick and increase fearfulness, when individuals face a safety investigation.
And of course any workplace incident will involve individuals.
But finding someone to blame isn't a solution for an unsafe system.
I've spent more than two decades analysing technologies, tools and environments to better understand how people perform in complex systems and what could keep them safer.
Safety investigations are necessary for understanding incidents and preventing future ones, but growing evidence suggests some investigative approaches can actually increase risky behaviour.
Management intolerance towards mistakes and prosecutorial investigation methods can prompt what I call ‘investigation trauma' – where the workers affected by a stressful safety incident are further traumatised by investigation processes and a lack of emotional support.
This creates a culture of fear: workers who are afraid to speak up and report near misses or hazards worrying they will be investigated and blamed, even if they are not at fault.
Critical learning opportunities to improve safety are lost and mental health takes a hit in occupations already at high risk for mental health conditions.
Public perceptions that victims of an accident will be unfairly blamed or scapegoated even appear in our entertainment.
On January 15, 2009, Captain Chesley "Sully" Sullenberger was hailed a hero after safely landing on New York's Hudson River, when both engines of US Airways Flight 1549 disastrously failed.
In the 2016 film recounting the incident, the hostile aviation investigators vilify the pilot and question his split-second decision-making.
Sure, Sully director Clint Eastwood subsequently admitted the screenplay fictionalised that aspect of the story, to increase drama and introduce ‘villains.'
But the perception persists that investigators – and companies and industries – want to name, blame and move on.
In real life, the Deepwater Horizon offshore drilling rig explosion in 2010 killed 11 workers, and became the largest oil spill in history.
US prosecutors brought, then dropped, charges of manslaughter against two rig supervisors. But the final US government report found the main cause was a defective cement job, among a constellation of contributory factors and systems issues.
Whether the threat of prosecutorial investigations is real or imagined, the impact on workforce fearfulness is immense.
And ultimately, the consequences could be fatal.
Since 2022, Australia's Workplace Health and Safety Act has identified ‘psychosocial risk', such as exposure to traumatic events, or unsustainable workload, as a workplace hazard.
‘Investigation trauma' is absolutely a psychosocial risk and workers' concentration, alertness, reaction time,and decision-making can all be impacted as their stress and fear increases.
On the flip side, psychological safety leads to physical safety.
And improving safety systems and employee supports through investigations can achieve both.
Over the next four years, for my Australian Research Council funded project Transforming incident investigation in safety-critical industries, my research team and I will assess how industry processes manage trauma for those involved.
The $1.2 million project will give us new knowledge about trauma created by workplace investigations and characterise a whole new class of hazard which is currently poorly understood.
This will include reviewing safety investigations by key authorities and agencies in transport including those in the resources sector, for patterns of language, tone and how incidents are framed.
I'll also be interviewing individuals in high-risk industries - both investigators and those who have faced, or may face, investigation.
In the meantime, I hope to increase awareness around the risks of ‘investigation trauma' and encourage organisations and managers to reflect on their own processes.
Closing the knowledge gap around ‘investigations trauma' will help identify better ways to conduct investigations in safety-critical workforces, with less trauma, and safer outcomes across the community.
CQ university's Professor Anjum Naweed. Credit: Supplied
Professor Anjum Naweed is a 2024 recipient of the prestigious Australian Research Council Future Fellowship. His groundbreaking research will assess how ‘investigation trauma' in high-risk industries is impacting workplace safety culture.
He's a member of the Appleton Institute, CQUniversity's Adelaide-based flagship research centre for behavioural sciences across physical activity, sleep and biological rhythms, and operational readiness.
The MNN Research Report 2025 provides insights into critical mining themes in Australia/Oceania, including top projects, C-suite priorities, risk, ESG performance and investor sentiment.
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REGULATION
Opinion: incident investigations should shake down safety systems, not trigger trauma
When things go wrong, how do we ensure workers are not re-traumatised?
Workers in high-risk industries are right to fear accidents – it's what helps prevent them. But fear of safety incident investigations can have the opposite effect. CQUniversity human factors and safety scientist Professor Anjum Naweed explains.
In Australia's safety-critical industries like resources, transport and health care, millions of dedicated people go to work with the real risk of not coming home.
Understandably, people begin their day with accidents in mind – attending toolboxes, doing risk assessments, examining safety notices, completing safety logs.
It's a healthy process (and often one required by legislation) to manage safety and prevent catastrophe.
But if something goes wrong, should workers end their day fearing investigation?
Research and industry reporting consistently finds human factors account for more than 90% of industry safety breaches.
I don't like the term "operator error." But try a Google News search for it, and you'll find countless accident investigations, blaming "operator error" for everything from oil spills, to amusement ride crashes, to train doors closing on passengers.
A 2008 study of Queensland mining safety made headlines when "operator error" was identified to be a contributing factor in 95% of all incidents.
Those numbers and stories stick and increase fearfulness, when individuals face a safety investigation.
And of course any workplace incident will involve individuals.
But finding someone to blame isn't a solution for an unsafe system.
I've spent more than two decades analysing technologies, tools and environments to better understand how people perform in complex systems and what could keep them safer.
Safety investigations are necessary for understanding incidents and preventing future ones, but growing evidence suggests some investigative approaches can actually increase risky behaviour.
Management intolerance towards mistakes and prosecutorial investigation methods can prompt what I call ‘investigation trauma' – where the workers affected by a stressful safety incident are further traumatised by investigation processes and a lack of emotional support.
This creates a culture of fear: workers who are afraid to speak up and report near misses or hazards worrying they will be investigated and blamed, even if they are not at fault.
Critical learning opportunities to improve safety are lost and mental health takes a hit in occupations already at high risk for mental health conditions.
Public perceptions that victims of an accident will be unfairly blamed or scapegoated even appear in our entertainment.
On January 15, 2009, Captain Chesley "Sully" Sullenberger was hailed a hero after safely landing on New York's Hudson River, when both engines of US Airways Flight 1549 disastrously failed.
In the 2016 film recounting the incident, the hostile aviation investigators vilify the pilot and question his split-second decision-making.
Sure, Sully director Clint Eastwood subsequently admitted the screenplay fictionalised that aspect of the story, to increase drama and introduce ‘villains.'
But the perception persists that investigators – and companies and industries – want to name, blame and move on.
In real life, the Deepwater Horizon offshore drilling rig explosion in 2010 killed 11 workers, and became the largest oil spill in history.
US prosecutors brought, then dropped, charges of manslaughter against two rig supervisors. But the final US government report found the main cause was a defective cement job, among a constellation of contributory factors and systems issues.
Whether the threat of prosecutorial investigations is real or imagined, the impact on workforce fearfulness is immense.
And ultimately, the consequences could be fatal.
Since 2022, Australia's Workplace Health and Safety Act has identified ‘psychosocial risk', such as exposure to traumatic events, or unsustainable workload, as a workplace hazard.
‘Investigation trauma' is absolutely a psychosocial risk and workers' concentration, alertness, reaction time,and decision-making can all be impacted as their stress and fear increases.
On the flip side, psychological safety leads to physical safety.
And improving safety systems and employee supports through investigations can achieve both.
Over the next four years, for my Australian Research Council funded project Transforming incident investigation in safety-critical industries, my research team and I will assess how industry processes manage trauma for those involved.
The $1.2 million project will give us new knowledge about trauma created by workplace investigations and characterise a whole new class of hazard which is currently poorly understood.
This will include reviewing safety investigations by key authorities and agencies in transport including those in the resources sector, for patterns of language, tone and how incidents are framed.
I'll also be interviewing individuals in high-risk industries - both investigators and those who have faced, or may face, investigation.
In the meantime, I hope to increase awareness around the risks of ‘investigation trauma' and encourage organisations and managers to reflect on their own processes.
Closing the knowledge gap around ‘investigations trauma' will help identify better ways to conduct investigations in safety-critical workforces, with less trauma, and safer outcomes across the community.
Professor Anjum Naweed is a 2024 recipient of the prestigious Australian Research Council Future Fellowship. His groundbreaking research will assess how ‘investigation trauma' in high-risk industries is impacting workplace safety culture.
He's a member of the Appleton Institute, CQUniversity's Adelaide-based flagship research centre for behavioural sciences across physical activity, sleep and biological rhythms, and operational readiness.
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