8.4.6 Recommendations The investigation should have highlighted both immedi-
ate causes and underlying causes. Recommendations,
both for immediate action and for longer-term improve-
ments, should come out of this, but it may be necessary
to ensure that the report goes further up the management
chain if the improvements recommended require author-
ization, which cannot be given by the investigating team.
8.4.7 Follow-up It is essential that a follow-up is made to check on the
implementation of the recommendations. It is also neces-
sary to review the effect of the recommendations to
check whether they have achieved the desired result and
whether they have had unforeseen ‘knock-on’ effects,
creating additional risks and problems.
8.4.8 Use of information The accident investigation should be used to generate
recommendations but should also be used to generate
safety awareness. The investigation report or a summary
should therefore be circulated locally to relevant people
and, when appropriate, summaries circulated throughout
the organization. The accident does not need to have
resulted in a three-day lost time injury for this system to
be used.
8.4.9 Training A number of people will potentially be involved in acci-
dent investigation. For most of these people it will only be
necessary on very few occasions. Training guidance and
help will therefore be required. Training can be provided
in accident investigation in courses run on site and also
in numerous off-site venues. Computer-based training
courses are also available. These are intended to provide
refresher training on an individual basis or complete train-
ing at offi ce sites, for example, where it may not be feas-
ible to provide practical training.
8.4.10 Investigation form Headings which could be used to compile an accident/
incident investigation form are given below:
➤
date and location of accident
➤
circumstances of accident
➤
immediate cause of accident
➤
underlying cause of accident
➤
immediate action taken
➤
recommendation for further improvement
➤
report circulation list
➤
date of investigation
➤
signature of investigation team leader
➤
names of investigating team.
Follow-up ➤
were the recommendations implemented?
➤
were the recommendations effective?
An example of an investigation form using 16 different
causes of accidents for analysis purposes is shown in
Appendix 8.1.