Learning from Safety Failure
RoSPA Accident Investigation Challenge supported by TUC, CBI, IOSH and ABI
Essential steps
Although in practice they may be telescoped together, the essential steps involved in investigation can be described as follows:
- taking prompt emergency action (providing first aid, making things safe);
- prompt reporting within the organisation and to other agencies where necessary;
- securing the scene (preventing disturbance of vital evidence..);
- deciding on the level of investigation required (e.g. according to safety significance, learning potential etc) and establishing terms of reference and allocating responsibilities in the investigation process;
- gathering the evidence (establishing the facts by gathering physical evidence, conducting witness interviews, identifying documentation etc);
- analysing and integrating the evidence (putting the facts together);
- identifying gaps in the evidence (significant unknowns) and seeking further evidence and/or clarification (for example, by studying previous events that may be relevant);
- developing and testing hypotheses - what happened, how, why etc (again looking further evidence if necessary);
- generating conclusions and recommendations ; and
- communicating recommendations and tracking closure with stakeholders.
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RoSPA is a registered charity: Registered Charity No: 207823 Patron: Her Majesty the Queen RoSPA Head Office: Edgbaston Park, 353 Bristol Road, Edgbaston, Birmingham B5 7ST, UK |
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