Islom karimov nomidagi

Event reconstruction in order to establish the exact sequence of events leading to the safety occurrence with its causal and contributory factors. The output of the reconstruction phase should be a set of events that agrees with recorded information and which unifies the views of the various persons who were involved in these events immediately before and after the occurrence.

Analysis of the information to assess the risk and provide explanation of the technical and operational factors, and underlying (including organisational) factors and issues. The analysis shall provide argumentation about why the occurrence happened and enable the drawing of conclusions and identification of safety actions to eliminate or mitigate the risk.