Establishing Findings and Developing Recommendations

An accident investigation should conclude with the investigation team accomplishing five key tasks:

1. Agreeing on the accident sequence based upon the facts gathered
2. Establishing the findings of the investigation
3. Identifying causal factors
4. Identifying contributing factors
5. Developing recommendations

Establishing Findings

1. Findings are the conclusions of the investigation team based on the chronology of events and factual data, weight of evidence, professional knowledge, and good judgment.
   
   
   • Each finding is an essential step in the accident sequence, but each finding is not necessarily the cause of the accident. Do not include any more information in each finding than is necessary to explain the event occurrence.
     
     
   • Findings can refer to events which occurred months or years prior to the accident. Lack of training and poor equipment maintenance are examples.
     
     
   • Where possible, findings should be supported by two or more facts discovered during the investigation.
     
     
   • Findings are grouped by category (human, material, and environmental) in the findings section of the investigation report. Number each finding consecutively. Precede each number with the word “finding.” For example: Finding 01, Finding 02, Finding 03.
     
     
   • At the end of each finding, reference the supporting documentation/evidence that supports it.
     
     
   • Ensure critical events required to sustain the accident sequence have not been omitted.
     
     
2. Categories of findings—The following three categories can help organize findings during an accident investigation:
   • Human (personnel involved or contributing to the accident or incident)
   • Material (equipment involved or contributing to the accident or incident)
   • Environmental (location of the accident or incident, geographic features, and weather conditions)
     
     
3. Developing findings—Write findings as full sentences, not bullet points. Use the past tense since the events have occurred in the past. For example: Due to lack of station maintenance, weather observations from remote automated weather stations were of questionable accuracy and provided potentially erroneous National Fire Danger Rating System indices.

Identifying Causal Factors

1. A causal factor is any behavior, omission, or deficiency that if corrected, eliminated, or avoided probably would have prevented the accident.
   
   
   • Findings (events or conditions) that started or sustained the accident sequence are the basis of causal factors.
     
     
   • Each causal factor must be supported by a finding. Although all findings are significant, not all of them relate to the accident sequence.
   
   Occasionally, an investigator may not be able to conclusively determine a specific causal factor. In these special cases, the investigator may choose to list two or three most probable causal factors. In rare instances, the causal factors may remain unknown.
   
   
2. Developing causal factors—Write causal factors in the active voice, clearly identifying the actor(s) and causal action, along with any necessary explanation. For example: Active voice—The vehicle operator did not use wheel chocks as required by policy. Passive voice—No wheel chocks were used by the vehicle operator.
   
   If it is not obvious, indicate which finding(s) was used to determine the causal factor(s)
   
   Apply the reasonable person concept. If a person’s performance or judgment was reasonable considering the accident’s circumstances, it is not appropriate to expect extraordinary or uniquely superior performance in such cases.

Identifying Contributing Factors

1. A contributing factor is any behavior, omission, or deficiency that sets the stage for an accident, or increases the severity of injuries or extent of property damage.
   
   Examples of contributing factors are fatigue, conflicting resource priorities, delay in taking appropriate action, or environmental conditions, such as rain or poor illumination. Contributing factors may be present during an accident but may not have prevented or mitigated the accident if they had not been present.
   
   
2. Developing contributing factors—Base contributory factors on the findings discovered during the investigation. Indicate which findings were used to determine the contributing factors.

Developing Recommendations

1. Recommendations are reasonable courses of action, based on the identified causal factors that have the best potential for preventing or reducing the risk of similar accidents.
   
   
   • The team leader and the chief investigator should lead the team in the development of recommendations.
     
     
2. Recommendations could include review of current policy, new policy, re-training personnel on existing requirements, or additional training needs. A recommendation is not needed for every causal factor. If an event was caused by failure to follow an existing policy, the recommendation may only require the people involved to be re-trained. Broad recommendations, such as to change the safety culture of the agency, are not appropriate.
   
   
3. The organization assigned responsibility for the corrective action should have authority commensurate with the nature of the recommendation. In some cases, more than one level in the agency or even other agencies will have action responsibilities.
   
   
4. Number recommendations consecutively, precede each number by the word “recommendation.” For example: Recommendation 01, Recommendation 02, Recommendation 03.
   
   
5. If a recommendation depends on test results or analyses that are incomplete when the factual section of the investigation report is sent, explain this and reference the test or analysis. If such information is critical to the completion of the factual section, the team leader should request an extension from the individual authorizing the investigation (failure to incorporate critical information could result in having to reconvene the team at a later date.)
   
   Recommendations Should Not:
   
   
   • Propose any punitive actions.
     
     
   • Propose briefing unit personnel on the accident. Such briefings are basic management responsibility and a normal function of safety managers and supervisors at all organizational levels.
     
     
   • Recommend that a new policy, regulation, or standard operating procedure is needed when established guidelines exist but are not followed.