#Incident investigation

Comprehensive incident management and accident investigation at industrial enterprises. Moving from mere blame-seeking to deep root-cause analysis (5W principle) and building a proactive culture. Transforming routines for 'Target Zero'.

95
items in this topic
Expert blog
September 28, 2026

AI as the Investigation Committee’s Assistant: From a Cloud Agent to Offline Incident Investigation

How we moved from our first cloud experiments to an operational “masking tool → AI agent → unmasking” workflow, then built a test offline investigation system, and are now preparing for the next step: Fire, a secure corporate AI environment.

Incident investigation Artificial intelligence Barrier approach
Expert blog
September 11, 2026

From Excel to an HSE dashboard and incident analysis without handing over personal data. Stage 1: the offline masker

You cannot simply upload a working spreadsheet or an explanatory note to a cloud AI: they hold full names, personnel numbers, contractors, phone numbers. The HSE director of SSGPO shows the first stage of his scheme — a local masker in a single HTML file: only an anonymized copy leaves the company, while the recovery key and the password stay inside. With ready-made prompts for building the tool.

Incident investigation Digitalization Artificial intelligence
Expert blog
Rinat Fatkhutdinov
Director
iTechnoPro
September 3, 2026

AI Agents in Health and Safety

A chatbot carries out one instruction and stops; an AI agent drives the task through to the result. We compare the two on a real end-to-end fatal accident investigation — and explain why managing agents is becoming a skill everyone needs.

Incident investigation Competence Digitalization
Expert blog
September 2, 2026

🛡️ Safety: The Sayano-Shushenskaya Dam Disaster Through the Lens of Process Safety

On 17 August 2009, 75 people died at the Sayano-Shushenskaya hydropower plant. We break the accident down element by element against Process Safety Management — and show why the disaster was predictable.

Incident investigation Risk management Industrial safety
Case
Vitaliy Kirilin
Head of the educational and methodical department
SIBUR
March 18, 2026

How to Establish a Technical Training Center: Lessons Learned

Creation of corporate technical training centers with a focus on practical training and the rejection of the academic approach. Educational programs are formed based on incident investigation reports, and active production staff are involved as instructors. The effectiveness of the system is measured by the trend of reducing production incidents after at least 60% of the target audience has completed the training.

Incident investigation Internal trainers Performance evaluation
Case
Rinat Fatkhutdinov
Director
iTechnoPro
February 5, 2026

AI + Automation in HSE

Implementing artificial intelligence tools to automate routine HSE processes. Practices include using AI bots to collect Near Miss data, hybrid search systems (RAG) for regulatory databases, software robots (RPA) for reporting, and generating engaging content for briefings.

Incident investigation Training Gamification
Case
Roman Portnyagin
Head of Investigation Process Development, Incident Investigation Department
Nornickel
December 18, 2025

Destructive Thinking Patterns: Who Hides the Truth During Investigations

A methodology for internal incident investigations that eliminates experts' cognitive biases. The approach is based on perceiving a person as an adapter of an imperfect system, rather than a mechanism, and avoiding evaluative words when formulating root causes.

Incident investigation Safety culture Forum 2025
Case
Margarita Anokhina
Director of Incident Investigation Department
Nornickel
December 18, 2025

Cardinal Safety Rules: Placebo or Effective Medicine

Implementation and optimization of Cardinal Safety Rules (CSR) in a large industrial company. Reducing the list to six key rules, strict enforcement (up to dismissal), and analyzing the impact on fatal injury statistics.

Incident investigation Safety culture Safety leadership
Case
Zaur Shugushev
Chief Cardiologist of Central Healthcare Directorate — Russian Railways, Head of Cardiovascular Pathology Center, Department Head, Doctor of Medical Sciences, Cardiovascular Surgeon
Russian Railways
December 17, 2025

Prevention of Cardiovascular Diseases

A workplace cardiovascular disease prevention system including occupational risk stratification, a five-level investigation of sudden deaths, and control of medical check-ups via a corporate network linked to VHI. Workers with critical illnesses are moved to light duty with a chance to return after successful treatment.

Incident investigation Risk management Health protection
Expert blog
Arsen Azizov
Lead Occupational Safety Specialist
Gazprom Transgaz Ukhta
November 21, 2025

The Swiss Cheese Model in Occupational Safety

The "Swiss cheese" concept, proposed by psychologist James Reason, explains how the overlap of vulnerabilities in different protection systems leads to industrial accidents. The article analyzes the functioning of the main levels of industrial safety — from design solutions to personal protective equipment — and the potential weaknesses of each of them. From the material, you will learn which practical methods, including barrier audits, redundancy of measures, and digitalization, help build a re...

Incident investigation Risk management Barrier approach
Expert blog
Ilya Zabugin
Deputy Managing Director for HSE
Pokrovsky Mine
November 21, 2025

A Modern Approach to Safety: Prompt Emergency Reporting

The article describes the implementation of an automated emergency notification system based on 1C, replacing verbal notification schemes. Depending on the severity of the incident, the system automatically sends mailings via corporate email or SMS messages to managers. Such a solution eliminates the human factor, reduces response time, and improves the quality of decision-making at critical moments.

Incident investigation Communications Digitalization
Expert blog
Arsen Azizov
Lead Occupational Safety Specialist
Gazprom Transgaz Ukhta
November 20, 2025

Why Eliminating Minor Non-Conformities Matters, or the "Broken Windows Theory"

The article explains the application of the "broken windows theory" in the field of occupational health and safety, according to which even minor deviations from safety rules lower the bar of what is acceptable and can trigger serious workplace injuries. The material examines how zero tolerance for minor violations, regular monitoring, and the personal example of managers help form a safety culture and prevent major accidents. The author also shows the need for a balance between strict control a...

Incident investigation Safety culture Safety audit
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