Conducting MVI Investigations

Step 5: Recommend Corrective Actions

The core reason for examining crashes is to identify corrective actions the organization will take to ensure other crashes do not occur because of the same acts, conditions or decisions that caused this crash. Corrective actions should speak directly to the underlying causes identified in your analysis.

Sometimes when you examine the facts it will be apparent that your employee did everything right - the actions or omissions of a third party caused the crash. It's still worth looking for ways to prevent reoccurrence (e.g. training on crash avoidance techniques) but there is little value in looking for corrective actions that simply aren't there.

Use the framework below to determine what corrective actions to recommend.

Organizational factors

For work-related crashes, much of the responsibility for changes aimed at preventing future crashes falls to the organization. The company sets the policies and procedures by which it requires employees to drive. The company is responsible to equip their employees with the training and supervision necessary to operate work vehicles, and to ensure work vehicles are fit for purpose. It is imperative that investigators look closely at organizational factors as they develop corrective actions.

Will inspections catch mechanical failures before they occur? Is the maintenance program all that it should be? Is there a gap in the grey fleet policy that allowed an employee to use their seriously deficient vehicle for work? How does the organization manage the trips employees take? Why was that employee delivering parcels when road conditions were treacherous? How do we strengthen our policies and how they are applied?

Human factors

Think about the people involved, their actions and inactions. Determine what they can do differently to prevent recurrence, and how they can be equipped and motivated to do so. Focus on practices and behaviours that the company can control or influence. For example, if driver fatigue was a key factor the recommendations could spotlight:

  1. What the employer and owners can do to make sure fatigue management is a safety priority
  2. What managers can do to ensure employees understand fatigue and what they can do to avoid it
  3. How supervisors and employees can collaborate to build schedules that avoid long driving assignments
  4. How individual employees can self-manage and self-assess to know when they are fatigued, and be empowered to pull over and rest.

Physical factors

If mechanical failures or conditions figured in the crash, consider the vehicles used for work. Are they designed and equipped so that they are fit for the purposes they are used? Do they have the right safety equipment? If environmental factors contributed to the crash, the organization can do very little to control the weather, but they can do quite a lot to manage if, when and how their employees drive during adverse weather conditions. Build recommendations around that understanding.

It's often tempting for investigators to make a "shopping list" of corrective actions - a long list actions it would be nice to do, but is rarely completed. Challenge your investigation team to arrive at the ONE THING that must be done to make sure this crash does not happen again. Keep the corrective actions list short, clear - and doable.

Building the Report

There are several formats for building a report. Choose one that works well for people in your organization. Often, a well-structured investigation form can serve as the foundation for a well-organized report. Below is a framework you can use to build incident investigation reports.

Summary

A brief summary of the incident including:

  1. Who was involved; description of vehicle(s) involved
    Depending on how the investigation report will be distributed, it is often appropriate to exclude names and other personal information of the people involved and witnesses. Instead, identify individuals as Driver A, Pedestrian B, Observer C, etc.
  2. What happened - use the sequence of events; include suitable photos of the scene
  3. When it happened - date, time; state day of the week or "day 11 of 12-day shift"
  4. Where it happened - location, address and qualifiers (e.g., busy street, steep hill) if relevant
  5. Names and roles of people investigating the crash

Conclusions

Provide an overview of WHY the incident occurred, as determined by the investigation. Summarize the immediate and underlying causes.

Recommendations

List the main recommendations aimed at preventing similar future events. Use a table that links each recommendation to the condition or finding that prompted it:

Underlying Cause Recommended Corrective Action
Improper planning and unrealistic scheduling:

Crew was assigned three extra pick-ups with no accommodations for mandatory pick-ups.

RWC should develop and implement a procedure to build and verify achievable work schedules.

These first three sections - the summary, conclusions and recommendations - are what most of the people who receive the report will actually read.

Main Report

1. Purpose and Objectives

Explain why the organization conducted the investigation and what it expected to achieve. Beyond the core objectives of identifying root causes and finding ways to prevent recurrence, there may also be legal requirements, company policies and other reasons to consider.

2. Incident Description

Use factual statements to describe the events that happened before, during and immediately after the crash. Provide details about who, what, when and where. Include relevant peripheral events or factors.

3. Investigation Methods

Describe the investigation team - participant names, positions and qualifications. Explain site visits made. Insert photographs, sketches and diagrams that contribute to the explanation. Describe interviews conducted and summarize what was learned. If you conducted any simulations, tests or reconstructions, include the results here.

4. Findings

Organize the findings - what was discovered, confirmed or learned - so readers can easily follow the facts and logic used to develop the recommendations. The TOP-SET framework is a common approach.

5. Recommendations

In addition to dealing with underlying causes in a comprehensive manner, explain the contributing factors and causes, and how they figured in the events and the incident. Link recommendations to findings.

6. Appendix

This information is important to the investigation but not essential to understanding the report and its recommendations. Include raw data and statistics, supporting diagrams, photos and interviews, a root cause analysis chart, copies of relevant documents, etc.

Continue Reading

Step 1: Respond to the Incident

Step 2: Gather Information

Step 3: Map the Sequence of Events

Step 4: Determine Underlying Causes

Step 5: Recommend Corrective Actions

Step 6: Implement Corrective Actions



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