Extent of the Investigation (SO1-AC2)

Incident investigations are conducted whenever and wherever incidents occur. The investigation team is usually based near the incident scene to allow them to more efficiently collect data by conducting interviews, gathering physical evidence, and so forth. Analysis of the root causes of incidents may occur anywhere but being near the personnel involved in the management of the personnel is preferable, as it helps foster discussions with personnel. Companies decide what combinations of consequences and frequencies are appropriate to trigger each type of incident feedback process:

• Formal investigation (root cause analyses [RCAs])
• Less formal investigation (apparent cause analyses [ACAs]), and
• Trending of incident data with no immediate

The extent of the investigation should be that unsafe conditions will be uncovered as well as causes. The extent should be detailed enough to find the errors that are caused. Therefore, it is necessary to extend the investigation to reveal some underlying factors in a chain of events that ends in an incident.

The important point is that even in the most seemingly straightforward incidents, seldom, if ever, is there only a single cause. For example, an "investigation" which concludes that an incident was due to worker carelessness, and goes no further, fails to seek answers to several important questions such as:

• Was the worker distracted? If yes, why was the worker distracted?
• Was a safe work procedure being followed? If not, why not?
• Were safety devices in order? If not, why not?
• Was the worker trained? If not, why not?