Post #6 - What to Do After an Incident: A HOP-Based Approach

 What to Do After an Incident: A HOP-Based Approach

Rethinking Incident Investigations in the Construction Industry

Ed Klein

When something goes wrong in the field—an injury, near miss, equipment damage—our first instinct is often to ask: "Who messed up?"

But as more of us in high-risk industries adopt the principles of Human and Organizational Performance (HOP), that question gets flipped on its head. The better question becomes: 

"What made sense to the people involved at the time?"

If you're in construction, you already know this isn’t easy work. It’s dynamic, unpredictable, and full of variability. Our people operate in high-consequence environments, often with incomplete information, changing weather, and evolving plans. So, when an incident happens, we owe it to our teams to go beyond blame and dig into how work is really done—not just how it’s written in the procedure.

Moving From Blame to Learning

Traditional investigations often focus on rule violations, decision errors, or training gaps. While these might identify symptoms, they rarely uncover the deeper story of how the system shaped worker actions. HOP challenges us to take a learning-centered approach instead.

This is where the Learning Review comes in.

What is a Learning Review?

A Learning Review is a structured but flexible way to understand an incident without defaulting to blame. Instead of isolating one root cause, it explores the context, conditions, and systemic influences that shaped what people did.

Here’s how to start implementing Learning Reviews after incidents in your operations:

1. Pause and Frame the Purpose

Before launching into questions, we start by being clear:

“We’re not here to find fault—we’re here to learn.”

This message needs to be communicated up and down the chain. It sets the tone for psychological safety and ensures people feel comfortable sharing what really happened, not just what they think leadership wants to hear.

2. Build a Timeline with Those Closest to the Work

Rather than reviewing paperwork in a conference room, we gather the folks who were directly involved and map out the sequence of events together. This can be done with sticky notes, digital whiteboards, or a standard whiteboard at the office or worksite.

Key questions include:

  • What was the goal at the time?

  • What did you see or know?

  • What pressures or constraints were in play?

  • What cues were you responding to?

This timeline becomes the backbone of the review—not to “catch” errors, but to understand the story behind the decisions.

3. Identify Normal Work, Not Deviations

In a HOP lens, we assume people are doing their best within the system. So, we look at how “normal” the situation was.

  • Were shortcuts taken because they were the only way to get the job done?
  • Was a critical step skipped because the equipment wasn’t available?

These aren’t excuses—they’re signals of system weakness. We’re not fixing people; we’re fixing conditions.

4. Look at Systemic Factors

Every outcome—good or bad—is the result of the system. Every system is perfectly designed to produce its current outcome.

This includes:

  • Design of procedures and tools

  • Communication and supervision

  • Environmental factors (weather, tide, etc.)

  • Production pressures

By identifying these influences, we can improve how work is supported, not just how it’s controlled.

5. Share the Learning

This step is often missed. Too many “investigations” vanish into a file cabinet. But if we want to build a learning culture, the insights must go back out to the field.

That might look like:

  • Toolbox talks based on the review

  • Visual “storyboards” shared in barge trailers

  • Leadership briefings focused on systems, not blame

  • Safety Alerts and other shares with industry groups

The goal is to help others recognize similar conditions and respond differently in the future—not to shame or punish.

Why This Matters in Construction

The construction industry is already complex without layering fear and silence on top of it. When we create space for honest conversation, we surface valuable insights that would otherwise stay hidden.

By embracing Learning Reviews, we not only improve safety—we show our people we trust them, but we also respect their expertise, and we’re serious about learning.

Because the real measure of a company isn’t how well it prevents every incident (spoiler: no one can)—it’s how well it learns from the ones that do happen.

Want to try a Learning Review after your next incident or near miss?
The next post will cover a more robust Learning Review Format.

Let’s keep building safer systems—together.


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