Investigating incidents conclusions about

A series of investigations initiated during this period led to the conclusion that DBS use by the mothers of these young women was the causative factor. Diethylstilbestrol is a developmental toxicant, because its effect was the result of exposures received in utero, but that effect - a rare form of vaginal cancer - was not fully expressed for about two decades following the exposure (the age at which the incidence of the disease peaked was later shown to be 19). The DES produced not only cancer but abnormalities of the sexual organs in both male and female offspring, most of which were not expressed until the children passed the age of puberty. 

So let s demonstrate how this might work, using an incident described earlier. Keep in mind that this is a simple exercise, and because you have not conducted a thorough investigation to collect all of the facts, it is possible your conclusions could be different from those shown in the example below. This is likely because each of us makes different assumptions that may or may not be correct. Remember that you can use this process to examine any incident that has involved you to learn more about the root causes and derive lessons that might prevent those from happening again. 

Comments made about incident investigation in the previously mentioned August 2003 Report of the Columbia Accident Investigation Board are identical to the conclusions I drew as a result of that research. As the following excerpts from that report are read, I suggest that safety professionals think about how they relate to the quality of the incident investigation systems in the entities with which they are involved. 

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