Doc. 90/13 Incident/Accident Investigation and Analysis

"Incident or accident investigation, analysis and understanding the causes of such events is a critical element of safety management. 

For any organisation, the overriding purpose in carrying out incident investigation is to understand why an incident happened in order to make improvements to prevent similar incidents happening in the future.

The purpose of this document is to provide guidance in respect of the key elements of the incident/accident investigation process, from collection of data and root cause analysis through to identification and sharing of improvement measures.

The document has been extensively revised throughout all sections and is intended for operational managers, safety managers and engineers and all those who may be involved in incident investigations."