Islom karimov nomidagi

Drawing conclusions on the basis of collected and analysed information, generally presented by the following categories:

1. 
   Main (direct) cause(s) and contributing factors leading to the occurrence;
   
2. 
   Findings that identify additional hazards which have risk potential but have not played direct role in the occurrence;
   
3. 
   Other findings that have potential to improve the safety of operations or to resolve ambiguity or controversy issues contributed to the circumstances surrounding the occurrence.
   

Identifying the lessons to be learned from a safety occurrence requires an understanding of not just what happened, but why it happened. Therefore, the investigation should look beyond the obvious causes and aim to identify all the contributory factors, some of which may be related to weaknesses in the system’s defences or other organisational issues.

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  Identification of safety recommendations and actions to be taken in order to eliminate or mitigate the safety deficiencies identified by the investigation. The safety recommendations are the main product of any occurrence investigation and are made in the final report.
  
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