May 6, 2026 | Mark Paradies

The Curse of the Accident Investigator

First Time I Heard of the Curse

I was teaching a 5-Day TapRooT® Course when I overheard four engineers talking during a break. They were discussing how much of a bummer it was to be in the class. I was horrified and had to ask them why being in the class was a problem. Maybe there was something I could do to make things better.

They told me there was nothing wrong with the class. They were enjoying it and had learned some valuable things that could help them in their career development. However, when they went back to work, they would be asked to conduct accident and incident investigations.

I asked them why that was a problem. What was wrong with doing investigations?

They said it wasn’t doing investigations that was the problem. The problem was that they had to do them in their spare time. And they didn’t have any spare time.

The engineers explained that they were evaluated on the projects they were working on. The deadlines were tight, and if they didn’t complete the project on time, they would get a negative performance review. When they were assigned an incident investigation, there was no change in their regular workload. Thus, the only way to get the investigation completed was to work nights and weekends. And giving up nights and weekends was a bummer.

Thus, the first curse of being an accident investigator is losing your time off without compensation.

Second Curse

I discovered this curse when I was asked to facilitate a major investigation at a large company. The client’s facility was involved in an accident that made headlines in The Wall Street Journal. The company’s Board of Directors was concerned that the investigation would not be independent, so they asked for an outside review.

I got a call from the senior safety professional who was on the corporate staff. He told me that he had convinced management to bring in an outsider to review the investigation. He asked me if I had the time.

I wanted to support the client, so I agreed to perform the review. I took two of us from System Improvements about two weeks to interview people, review their SnapCharT® and use of the Root Cause Tree® Diagram, make some additions to the original investigation, and prepare a management briefing for the Senior VP, his staff, and line management.

As I gave the presentation, I noticed something peculiar. The VP’s chair was scooting closer and closer to the Senior VP’s chair. A gap was forming between the VP and the Division General Manager. Sure enough, about two weeks after the presentation, the General Manager was transferred to a faraway staff job (the equivalent of being fired).

I called the senior safety professional about the investigation and why he hadn’t wanted to perform the review. He said:

“I knew because of the seriousness of the accident that some senior manager’s head was going to roll. I didn’t want to be the one seen as responsible and be blamed for a senior manager losing his job. I knew a consultant wouldn’t suffer any long-term blame, so I thought I should get someone from SI to come and do the review.”

So that’s the second curse of the accident investigator. Being blamed for getting people fired or demoted (even though there was nothing about firing someone in the review).

Third Curse

This curse is probably the first curse that I observed. A team was assigned to find the root causes of an accident at a nuclear plant. This was early in my career, and the team didn’t have any formal training in root cause analysis.

The team presented their results (which weren’t perfect but weren’t too bad considering their training). The senior manager started yelling at them. They didn’t find the “root cause” that he thought they should have. He sent them back to redo the investigation and come back with the “right” root cause.

And that’s the third curse of the accident investigator. To be assigned a root cause analysis without any training and then have to guess what the boss wants. And if you guess wrong? A humiliating tongue-lashing in front of senior management.

Removing the Curses

A good root cause analysis system with training for investigators and management can go a long way to removing these three curses.

In the first example, if a great root cause analysis system had been properly implemented, they wouldn’t be asking investigators to perform investigations in their spare time. Root cause analysis requires adequate resources to be completed successfully.

In the second example, if the Division General Manager had been trained in root cause analysis and knew that he was expected to lead change in the division to prevent future accidents using effective corrective actions based on thorough root cause analysis, he might have been able to save his job. The investigator wouldn’t have to worry about negative blowback because there wouldn’t be a firing.

In the third example, if managers were properly trained, they would know better than to expect a single “root cause” and would know which questions to ask to review a root cause analysis.

Thus, here are the corrective actions needed to remove the accident investigator’s three curses:

1. When you implement a root cause analysis system, plan your implementation to have the resources needed for thorough investigations. See the improvement program checklist and description of each item on the checklist in Book 2, TapRooT® Root Cause Analysis Implementation, for ideas. The checklist is shown below (reproduced by permission).

2. Have training for all your managers – especially senior management. The training should include their role in root cause analysis and the negative impact of blame. We have a course that can be customized for your senior managers. See THIS LINK for more information. This will help solve curses 2 and 3.

3. Send your accident investigators to the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. This will help them find the real, fixable causes of accidents. They will learn interviewing techniques and how to present what they found to management. You can have a course at your site (CLICK HERE for a quote or call us at 865-539-2139) or send people to one of our upcoming public 5-Day Courses (CLICK HERE for dates and locations).