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Report on Findings, Recommendations and Remedial Actions (SO4-AC1)
Completion requirements
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The team should identify and document the responsibility for the necessary corrections, corrective actions or preventative actions. These should be reviewed to ensure all necessary actions are identified.
Determining recommendations and conclusions: This checklist may help the investigators when determining the recommendations.
What systems failed?
- How can we prevent failure or make it less likely?
- How can we detect approaching failure?
- How can we detect failure when it occurs?
- How can we control failure and minimise the consequences?
- What does the system do?
- Why do we do this?
- What could we do instead?
- How else could we do it?
- Which persons failed?
- How can we make failure less likely?
- What is the purpose of the person’s action?
- What specific items in the system triggered the accident/incident?
Based on the results of the evaluation, the responsible person should develop, prioritize, approve, track and complete all actions in a timely manner to effectively make recommendations.
The recommended actions must now be prioritized based on the significance and impact of each issue. The levels of significance and impact of each identified issue defined during the evaluation are major factors in determining the amount and priority of resources (budget, personnel, time, etc.) utilized to implement the actions and the degree of tracking of and reporting on the status of actions to successful completion.
To improve safety, it is important to develop and implement remedial measures that better address the causes and consequences of incidents.
