The most important final step is to come up with a set of well-considered recommendations designed to prevent recurrences of similar incidents. Recommendations should:
i. be specific
ii. be constructive
iii. identify root causes
iv. identify contributing factors
v. Resist the temptation to make only general recommendations to save time and effort.
For example, you have determined that a blind corner contributed to an incident. Rather than just recommending “eliminate blind corners” it would be better to suggest:
– install mirrors at the northwest corner of building X (specific to this incident)
– install mirrors at blind corners where required throughout the worksite (general)
Never make recommendations about disciplining a person or persons who may have been at fault. This action would not only be counter to the real purpose of the investigation, but it would jeopardize the chances for a free flow of information in future investigations.
In the unlikely event that you have not been able to determine the causes of an incident with complete certainty, you probably still have uncovered weaknesses within the process, or management system. It is appropriate that recommendations be made to correct these deficiencies.
The Written Report
The prepared draft of the sequence of events can now be used to describe what happened. Remember that readers of your report do not have the intimate knowledge of the incident that you have so include all relevant details, including photographs and diagrams. Identify clearly where evidence is based on certain facts, witness accounts, or on the team’s assumptions.
If doubt exists about any particular part of the event, say so. The reasons for your conclusions should be stated and followed by your recommendations. Do not include extra material that is not required for a full understanding of the incident and its causes such as photographs that are not relevant and parts of the investigation that led you nowhere. The measure of a good report is quality, not quantity.
Always communicate your findings and recommendations with workers, supervisors and management. Present your information ‘in context’ so everyone understands how the incident occurred and the actions needed to put in place to prevent it from happening again.
Some organizations may use pre-determined forms or checklists. However, use these documents with caution as they may be limiting in some cases. Always provide all of the information needed to help others understand the causes of the event, and why the recommendations are important.