Accident Investigation Protocol - getting the Events to Learn from
The accident / incident investigation protocol describes the process to learn form from unwanted events such as
accidents, incidents, complaints, etcetera.
The main items that should be part of an accident
investigation protocol are given below:
The importance of learning from unwanted events should be made clear. This can be done in various ways: written
communication, training, toolbox meetings etc.
knows the problems that lay ahead and has taken measures to (1) prevent their
occurrence and (2) cope with their consequences should they nevertheless take
The main reason for learning from unwanted events is to eliminate and reduce undesired or unwanted events and
their consequences such as:
- human suffering
- material damage
- liability claims
- product losses
- company image damage
- loss of clients
with the aim to:
- maintain good stakeholder relations
- control production cost
- optimize continued profitability
What? Whom? When? How?
It is important to define what unwanted events should be reported, investigated and analyzed, by whom, when and
how and how remedial actions shall be managed to completion. The broader the definition of "unwanted event" is, the
more opportunities there are to improve the efforts to eliminate and/or reduce human suffering and unnecessary cost
Cause - Consequence model
It is important to accept a model that relates the unwanted event and its outcome to the management system. That
way a manageable system can be set up and communicated in which all levels in the organization will be able to play
their roles. The "domino model" provided via this website is generally accepted and can be easily applied to
various areas of business management: safety, quality, cost control etcetera.
Classification of Risk
For involvement and attention of higher management levels in the investigation, analysis, development and
follow-up of remedial actions, it is important not only to look at the actual results of an event but - even more
so - to establish what the results could be if circumstances would have been slightly different. A small fire
noticed during the initial phases could be extinguished easily but when unobserved, it could grow to a catastrophe
taking many lives and causing unprecedented damage.
Determining the potential risk is the objective of risk classification. The outcome of the risk classification process helps to
- which levels of management should be involved
- which method should be used fro investigation and cause analysis
- whether a team approach should be used to contribute to investigation and analysis; possibly including
- the management level of the team chairperson
- selecting remedial actions and deciding budget provisions
The protocol shall determine when a "root" cause analysis shall be carried out, depending on the level of risk
Such root cause analysis is best carried out through a team approach. Preferably these analyses should be done
under the guidance of a "facilitator" with sufficient knowledge and expertise with the analysis system being used.
The role of this person is of particular importance if the analysis data will be put in a data base for future use
and retrieval of information.
Systems used for cause analyses may include: SCAT (Systematic Cause Analysis Technique), MORT (Management
Oversight and Risk Tree); Causal tree ("Arbre des Causes") and others. A good investigation report form may also be of help when supported by a
Clear responsibilities should be established for:
- reporting of accidents / incidents defined in the protocol
- investigation of these accidents / incidents to collect facts
- cause analysis to uncover the causes that have led to the accident/incident
- development and follow-up of remedial actions
Responsibilities should preferably be put in writing and communicated to the persons concerned.
Training, Instruction, Communication
People with important roles in the "Learning From Accidents" process should know what is expected from them and
how they should carry out their roles in the process.
These roles are to include all important steps as indicated under "Responsibilities" above.
Conveying the message could range from instructions to operational personnel during toolbox- or safety meetings
to more extensive (external) training of facilitators in acquiring the techniques to be used in carrying out the
investigation and the cause analysis.
An investigation team should be used as determined by the level of the risk classification or otherwise.
The team can also be used to convey the importance of learning from accidents to all people on the investigation
team. Of particular importance to also include operational personnel as it will convey to them the importance of
reporting accidents / incidents. At the same time higher management levels should be included whenever possible to
demonstrate their management commitment and support through taking remedial actions to eliminate or prevent similar
events in the future.
The investigation team approach is "top down - bottom up" in practice.