Management System Success is Management Success


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[1] Risk Management, Safety and Control of Loss - Protecting Your Organization

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My books Success in Safety Improvement Model Management System Success Improvement Process 17-Step Process Improvement Process Rating Management System Structure Management System Content Improving the Management System The Audit Management System Rating International Safety Rating System Accidents and Incidents Accident Investigation Protocol Safety Opinion Survey

Accident Investigation - Learning from Unwanted Events

The Accident Investigation Protocol is a guide to learning from accidents, incidents and other types of unwanted events.


Purpose of Accident Investigation


The importance of learning from unwanted events should made be clear. This can be done through various ways, written communication, training, toolbox meetings etc.



A good management team

knows the problems that may lay ahead and has taken measures to (1) prevent their occurrence and (2) cope with their consequences should they nevertheless take place


The main reason for learning from unwanted events is to eliminate and reduce undesired or unwanted events and their consequences such as: 

  • suffering due to personal injury and occupational illness 
  • damage to product, equipment and the environment 
  • liability claims
  • loss of customers
  • company image damage

with the aim to: 

  • maintain good relations with employees and other stakeho0lders
  • control production cost  
  • optimize continued profitability


It is important to define what types of unwanted events must be reported, investigated and analyzed, by whom, when and how and how remedial actions shall be managed to completion. The broader the scope of the definitions, the more opportunities there are to improve the efforts to eliminate and/or reduce human suffering and unnecessary cost of production.


Accident Investigation model


It is important to accept a model that relates the unwanted event and its outcome to the management system. That way a manageable system can be set up and communicated in which all levels in the organization will be able to play their roles. The model provided via this website is generally accepted and can be easily applied to various areas of business management: safety, quality, cost control etcetera. 


Bird Model - accident investigation relating losses to management system



Classification of Risk - determine with events to investigate


Risk classification is important to determine the potential risk. The outcome of the process helps to: 

  • which levels of management should be involved  
  • whether a cause analysis shall be carried out
  • which methods should be used for investigation and cause analysis 
  • whether a team approach should be used to contribute to investigation and analysis; possibly including (external) expertise  
  • the management level of the team chairperson  
  • selecting remedial actions and deciding budget provisions  
Accident investigation responsibilities


Clear responsibilities should be established for: 

  • reporting of accidents / incidents defined in the protocol  
  • investigation of these accidents / incidents to collect facts  
  • cause analysis to uncover the causes that have led to the accident/incident  
  • development and follow-up of remedial actions  

Responsibilities should preferably be put in writing and communicated.


To make sure that remedial actions will be carried our properly and in time, consider the following functions:

  • event coordinator - person responsible for everything that is related to the accident, incident or event, including the actions to be taken
  • action owner - person responsible to assure that the action is carried out properly an in time. This could be the person who actually carries out the action or a person who makes sure that somebody else, possibly outside the company or organization, carries out the work.

For further details go to "accident and incidents" and follow the reading sequences indicated at the bottom of the pages.  


Accident investigation is a main source for system improvement 

Learning from accidents, incidents and other unwanted occurrences is vital to improve the entire sequence involved in the causation sequence, all the way up to the  management system.


NEXT PAGE is Accident Analysis

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