Process Safety Investigations – Are You Just Checking the Box?

When incidents occur in high-risk industries, they leave more than just reports and data—they raise important questions. What happened? Why did it happen? And how can we reduce the chance of it happening again? 

Too many investigations stop at compliance. Using Human and Organizational Performance (HOP) turns every incident into an opportunity for real, systems-based learning. 

Study to Understand—Not Just Comply

Regulations like OSHA’s PSM and EPA’s RMP set the baseline: form a team, meet deadlines, document what happened. In most cases involving human error, the mistake or violation has happened before. These errors often stem from underlying organizational or systemic issues that make the action seem reasonable at the time. Addressing these broader contributing factors, when within scope, can lead to improvements across the organization, rather than just preventing the same error from happening again in the same way.  

HOP flips the script—acknowledging that people will make mistakes and that context, culture, and leadership shape those mistakes. By applying HOP principles, we move beyond a checklist and toward insights that genuinely prevent the next incident. 

The Trouble with “Equipment Failure” and “Operator Error”

A conclusion of “valve malfunctioned” or “operator didn’t follow procedure” is easy—and ineffective. HOP investigations ask: 

• Why did the equipment fail? Was the design mismatched to operating conditions? Were maintenance schedules realistic? 
• Why did the operator choose that action? Were procedures clear and practical? Was workload or fatigue a factor? 
• What organizational pressures drove decisions? Did leadership goals conflict with safe operation? 

These questions probe the systems, habits, and cultural blind spots that set the stage for failures. 

HOP: A New Lens for Deeper Learning 

At the heart of HOP are five guiding principles: 

1. People make mistakes. Error is inevitable. 
2. Blame fixes nothing. Fixing systems, not people, drives improvement. 
3. Context drives behavior. Look at the environment and conditions that shaped decisions. 
4. Learning is vital. Treat every incident as a learning opportunity. 
5. Response matters. How you respond to an incident sets the tone for future reporting and transparency. 

By embedding these principles into every step—data collection, team interviews, causal analysis—we uncover root causes that standard RCAs miss. 

Tools Matter. But HOP Expertise Matters More 

Traditional RCA tools (5 Whys, Fishbone, Logic Trees) are essential—but only as powerful as the team wielding them. Credentials and expertise that matter include: 

• Advanced RCA certification in methodologies like TapRooT® and Bowtie 
• Practical HOP mastery, drawn from leading thinkers (Conklin, Dekker) and human-factors best practices 
• Just-culture facilitation, ensuring candid conversations without fear of punishment 

Don’t just run through a methodology; create the psychological safety needed for teams to share honest insights. 

You Can’t Investigate What You’re Afraid to Find 

Real system issues often point back to leadership or cultural gaps. As one investigator noted: 

“We discovered leadership had delayed action on a known hazard due to budget concerns. Months later, the same root cause triggered another incident.” 

Mechanical or technical causes may be fully described in a bi-modal assessment; a valve failed or held. But that binary view misses the deeper story. Only a curious, HOP-driven approach can shine light on the organizational and human factors that shaped how and why the failure occurred. It’s this systems-based curiosity that reveals the complex pathways leading to incidents—pathways that often begin long before a valve sticks or a switch fails. 

Why Montrose? Because HOP-Driven Expertise Doesn’t Guess 

Our incident-investigation team brings together: 

• Decades of cross-industry experience (oil & gas, chemicals, pharma, manufacturing) 
• Deep human-factors credentials, including NEBOSH/NEBOSH-level incident-investigator diplomas framed by HOP insights 
• HOP-based frameworks that reveal systemic and cultural root causes 
• A commitment to learning and continuous improvement, not blame 

We’re not just here to help you respond to incidents. We’re here to help you prevent the next one.

Let’s Make Safety Stronger Together

Whether you’re addressing a recent incident or building proactive resilience, Montrose’s HOP-powered investigations will uncover the true drivers of risk—and help you build robust systems, healthy cultures, and safer operations. 

Contact us to learn how HOP can elevate your incident-investigation program.