3295 Reporting, investigating and learning from incidents, accidents and events

Overview:

Incident investigation, and the resulting learning, is a key business performance activity.  However, international regulators have expressed concerns with the ability of organisations to learn, noting the need for:

More rigorous incident analyses that uncover underlying causes and contributing factors.

• Operators should clearly prioritise which incidents, including near-misses, warrant investigation and integrate human and organisational factors considerations into their processes.
• Learnings from incidents should be widely shared and analysed thematically across the industry, with systematic application and follow-up to ensure effectiveness.
• A shift toward a learning culture, rather than one of blame, is encouraged.
• Key performance indicators should track trends in incident recurrence, categorisation of causes, adherence to investigation procedures, and implementation of recommendations.

This document supersedes EI 3295 Learning from incidents, accidents and events (first edition), published in 2016.  It has been largely rewritten and heavily expanded to provide more detailed good practice guidance on the entire incident investigation and learning process.

The guidance was developed based on stakeholder input, representing over 50 organisations from various sectors, as well as feedback from investigation and learning specialists.

It provides comprehensive guidance, spread across 14 chapters, covering:

• reporting of events;
• investigating;
• learning;
• action planning, and
• making changes.

The guidance is not intended to be read cover to cover. Individuals can consult relevant chapters based on their role in the learning process.  Each chapter includes a ‘checklist’ summarising the guidance.

Additional materials