Uncovering the Real Drivers of Repeat Incidents in Organizations Beyond Human Error

By Michael Matthew — Safety.Inc | Certified Health & Safety Consultant | Operational Risk Management Professional

Repeat incidents in organizations cause frustration, lost time, and wasted resources. Leaders often find themselves stuck in a cycle of surface-level investigations that point to generic root causes like “human error.” This approach leaves the true drivers of failures hidden, allowing problems to resurface again and again. To break this cycle, leaders need to adopt advanced investigation methods and embrace Human and Organizational Performance (HOP) principles. These tools help uncover the real precursors behind incidents, enabling meaningful change.

This post explores why traditional investigations fall short, how deeper causal analysis reveals true failure drivers, and practical steps leaders can take to address repeat incidents effectively.

Incident investigation board showing complex causal relationships

Why Surface-Level Investigations Fail to Stop Repeat Incidents

Many organizations rely on quick investigations that identify “human error” as the root cause. This label is easy to assign but does not explain why the error happened. It treats human mistakes as the problem instead of a symptom of deeper issues.

Common frustrations with surface-level investigations include:

• Generic root causes such as “lack of training” or “failure to follow procedures” that do not lead to actionable solutions.

• Repetitive findings that fail to prevent similar incidents from happening again.

• Blame culture that discourages open discussion and learning.

• Missed organizational factors like poor design, unclear expectations, or system weaknesses.

  
  

When investigations stop at blaming individuals, organizations miss the chance to improve systems and processes that shape behavior. This leads to a cycle where incidents repeat, and frustration grows.

The Importance of Advanced Investigation Methods

Advanced investigation methods go beyond blaming people. They use structured approaches to dig deeper into the conditions and decisions that led to an incident. Techniques such as causal factor charting, barrier analysis, and the use of HOP principles help reveal the complex interactions between humans, technology, and organizational systems.

Human and Organizational Performance (HOP) focuses on understanding how people perform in real work environments. It recognizes that:

• Humans are fallible, and errors are normal.

• Most errors result from system weaknesses, not individual negligence.

• Systems should be designed to anticipate and mitigate errors.

• Learning from incidents requires a no-blame approach that encourages transparency.

  
  

By applying HOP, leaders can shift from blaming individuals to improving the environment where work happens. This shift creates safer, more reliable organizations.

How Real Causal Analysis Uncovers True Drivers of Failures

Real causal analysis looks beyond the immediate error to identify underlying causes. It asks questions like:

• What conditions allowed the error to occur?

• Were there conflicting goals or pressures on workers?

• Did the system provide clear guidance and support?

• Were there communication breakdowns or missing information?

• How did organizational culture influence decisions?

  
  

For example, a manufacturing plant might see repeated equipment failures blamed on operator mistakes. A deeper causal analysis could reveal:

• Inadequate maintenance schedules due to budget cuts.

• Poorly designed controls that confuse operators.

• Lack of feedback mechanisms to alert teams about early warning signs.

• Pressure to meet production targets that encourage shortcuts.

  
  

This level of analysis uncovers actionable insights that surface-level investigations miss.

Why “Human Error” Is a Symptom, Not a Root Cause

Labeling incidents as caused by “human error” oversimplifies complex situations. Human error is the final step in a chain of events, not the starting point. It signals that something in the system allowed the error to happen.

Consider a hospital where medication errors occur. Saying “nurse error” ignores factors like:

• Confusing medication labeling.

• Interruptions during medication preparation.

• Inadequate staffing levels.

• Poorly designed electronic health records.

  
  

Focusing on human error alone leads to punitive measures rather than system improvements. Recognizing error as a symptom encourages leaders to explore the real causes and prevent future incidents.

Identifying and Addressing Real Precursors Behind Repeat Incidents

To tackle repeat incidents, leaders should focus on identifying precursors—early signs or conditions that increase the likelihood of failure. These include:

• Workload pressures that lead to shortcuts.

• Inconsistent procedures that confuse workers.

• Lack of training or unclear expectations.

• Communication gaps between teams.

• Equipment or technology limitations.

  
  

Practical steps to address these precursors include:

• Conducting thorough investigations using advanced methods that map out causal factors.

• Engaging frontline workers to understand real work conditions and challenges.

• Implementing HOP principles to design systems that anticipate human limitations.

• Creating a culture of learning where incidents are openly discussed without blame.

• Regularly reviewing and updating procedures based on incident learnings.

• Using data and trends to spot patterns before incidents occur.

  
  

For example, a logistics company noticed repeated delivery delays blamed on driver errors. By involving drivers in investigations, they discovered unclear routing instructions and unrealistic delivery schedules. Adjusting these factors reduced errors and improved on-time performance.