Incident investigation action recommendations

A large portion of these common events can be linked to less than adequate follow-up of recommendations from previous incident investigations. The earlier investigation teams may have properly identified underlying root causes, submitted suggested preventive actions, and attempted to share results yet the repeat occurrences continue due to incomplete implementation of recommendations or ineffective sharing of lessons learned between potentially affected parties. 

In summary, developing the recommendations is a responsibility of the incident investigation team. Implementing the recommendations is a management responsibility. The inclusion of the elements of the recommendation in daily work practice is the responsibility of each individual affected by the recommended action. 

This 51-page publication is highly recommended as a reference for those who would evaluate and improve their incident investigation systems. A Guide for Identifying Causal Eactors and Corrective Actions is its centerpiece. Use of the Guide requires a systematic... 

Since this integrated approach is intended for use by incident investigators who may not have received any formal human factors training, it is useful to provide guidance on the generation of actions, or recommendations for action from the analysis. Such guidance might include ... 

The facts identified during the investigation should lead to conclusions. These conclusions should lead to recommendations. Recommendations lead to action planning—it is important that the corrective action plan be based on the conclusions from the investigation analysis. Action planning leads to prevention. Any facts that do not add to the sequence of events or that do not support a conclusion should not be included in the incident investigation report [5],... 

Recommended preventive actions should make it very difficult, if not impossible, for the incident to recur. The investigative report should list all the ways to foolproof the condition or activity. Considerations of cost or engineering should not enter in at this stage. The primary purpose of incident investigations is to prevent future occurrences. Beyond this immediate purpose, the information obtained through the investigation should be used to update and revise the inventory of hazards, and/or the program for hazard prevention and control. For example, the Job Safety Analysis should be revised and employees retrained to the extent that it fully refiects the recommendations made by an incident report. Implications from the root causes of the accident need to be analyzed for their impact on all other operations and procedures [6]. 

A comprehensive safety investigation not only looks at how an incident occurred, but also looks at why it occurred. Most importantly, the investigation recommends corrective actions that can be taken across the organization to prevent such incidents happening again. An incident investigation should be seen as a safety improvement process. It is not the purpose of ICAM to apportion blame or liability. 

Without participating in the detail of accident investigation, it is very difficult to appreciate the role of human behaviour in accident causation and hence to recommend or implement the most effective responses. Similarly, sole reliance on numbers of accidents/incidents in the organization as a guide to safety performance can be misleading, if the behavioural component is not understood. They do not show whether individual managers/supervisors are effectively dealing with prevention or if further action is required to prevent future accidents and losses. 

Each work-related incident with the potential to cause physical harm to employees should be investigated. Records of the hazards identified, the assessments, and the actions taken or plans to control those hazards should be documented. Some recommended methods for conducting assessments will be discussed in Chapter 15, on job hazard analysis (JHA). 

The intent of the investigation should be to learn from the incident and help prevent similar incidents. A corrective action program should be established based on the findings of the investigation in order to analyze incidents (e.g., uncontrolled release or non-compliant pollution incident) for common root causes. The corrective action prc ram is a followup system to the incident analysis procedures. The investigation should be expedited and findings and recommendations resolved in a timely manner. 

A required outcome of applying the ICAM process is the formation of clear recommendations to address deficiencies in system processes. The investigation team must make recommendations which address all absent or failed defences and all organizational factors identified as contributing factors. The investigation into the RailCorp incident resulted in several Recommended Safety Actions being proposed. Some of these are outlined in Table 12.2 below. 

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