Incident Investigation engineering information

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]. 

If STAMP has been used as the basis for previous safety activities, such as the original engineering process or the investigation and analysis of previous incidents and accidents, a model of the safety-control structure may already exist. If not, it must be created although it can be reused in the future. Chapters 12 and 13 provide information about the design of safety-control structures. 

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