Critical to this element is the understanding that an internal safety investigation is NOT about apportioning blame to individuals following an incident or accident. The intent of an investigation is to establish causal factors, and therefore strategies and defences to prevent reoccurrence.
Every accident and incident must be reported. Not every accident or incident is investigated. Investigations that are undertaken vary in extent and focus. There may be instances where only certain aspects (such as the HF contribution) needs to be analysed and investigated. Resources may be limited (particularly time) so the outcomes need to identify systemic risks and hazards to an organisation.
Investigating triggers as recommended by ICAO are shown on the right.
The SMS manual contains the procedures and processes for an investigation. Specifically it should detail:
- The scope of the investigation
- All personnel involved in the investigation
- Any SMEs required
- Recording of the findings
- Any trend analysis
- Any training benefits
- Which personnel need to be interviewed
- The timeframe for completion
- How the outcomes will be communicated within the organisation.
The investigation should identify what happened and why it happened. Root cause analysis may be applied as part of the investigation process. Ideally, the people involved in the event should be interviewed as soon as possible after the event. The investigation should include:
- Establishing timelines of key events, including the actions of the people involved
- Review of any policies and procedures related to the event
- Review of any decisions made related to the event
- Identifying any risk controls that were in place that should have prevented the event occurring
- Reviewing safety data for any previous or similar events.
Human Factors influences identified in the investigation
When conducting an investigation, there will always be some form of Human Factors involvement. The use of the SHELL model or the Accident Causation model are useful in determining where the HF breakdown occurred or which HF defense failed.