The purpose of an incident investigation is to protect precious lives and take steps to prevent an incident from happening again. The final three steps are imperative to preventing any further incidents.
Step 6: Recommend Corrective and Preventive Actions
At least one recommendation for each key factor should be identified, in some cases, a broad recommendation may address multiple key factors.
Recommendations exist as either corrective actions or preventive actions. Corrective actions are intended to fix a hazard while preventive actions prevent a hazard from occurring.
Step 7: Document and Communicate Findings
Clearly define what the expected results are from a particular recommendation and set priorities for each action, identifying which ones should be completed before operations resume. Any recommendations or improvement suggestions that are not associated with the incident facts or situation should not be included in your final report.
Communicating the information you have gathered, the lessons you have learned, and your recommended solutions will go a long way toward preventing incidents from happening again. When it comes to incident investigation, there are two levels of formal communication:
- First, there is an official incident investigation report with a limited distribution.
- Second is a widely-distributed flyer to communicate contributing factors of the incident and chief lessons learned from the incident.
Step 8: Follow Up
The final step of incident investigation is to follow up on your recommendations for corrective or preventive actions to be sure they were implemented and are effective. The goal of follow-up is to prevent a recurrence of the incident.
Ensure recommendations receive prompt attention by creating an action plan. Keep in mind that some recommendations may look good on paper, but are not that realistic to put into place. Be sure to periodically track the progress of your recommendations and prior to final closure of a recommendation, determine and verify that the action is completed and fully addressed the original intent of the recommendation.