As described in this chapter, what are the basic steps of conducting an incident investigation? Why it is important to identify all of the causal factors of an event? How does the development of corrective actions factor into the investigation process?

Question

What will be an ideal response?

Answer 1

First, note that for any injuries that occur, the injured persons are to be cared for immediately. The first step in the investigation process is to gather all available preliminary information pertaining to the event, identifying all involved parties to the event and any witnesses; obtaining written statements from the involved person(s) and any witnesses; taking photographs and drawing diagrams of the event and the area in which it happened; and contacting applicable leadership to inform them about the event. The second step is to conduct a risk assessment of the event to determine the level of risk, priorities for mitigation, potential for reoccurrence and severity, etc. The third step is to determine all causal factors which will help to determine true root causes for which factual information can be reviewed (step 4) and corrective actions can be employed (step 5). Identifying all causal factors of an event could help to uncover multiple failures or deficiencies in the safety system. Corrective actions should not be designed to treat only the symptom (e.g. retrain the employee on the proper use of hand signals while assisting with movement of aircraft), but it should rather address the failure of the system (e.g. implement use of hand signal behaviors to observation process).