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Conclusions and Recommendations



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Conclusions and Recommendations


During an investigation, it is common to come across hazards that have not been addressed but are not directly related to the occurrence. The conclusions however, should focus on the factors that are related to the event in some way and other channels should be used to rectify the other hazards.

Once the list of factors and contributors is complete, a list of reccomendations needs to be made.

Reccommendations should:


  • be tied to a specific factor or contributor.

  • address each and every factor and contributor.

  • only address the factors and contributors that caused or are related to the event.

  • be focused on the prevention of similar events from happening again.

  • avoid punitive actions; these are unlikely to prevent future occurrences but are very likely to limit cooperation in future investigations.

  • preferably offer short, medium and long-term solutions.

  • be as specific as posssible and avoid generalizations (e.g. procedures for XXX need to be reviewed).

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