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Stage 3: Prepare the investigation - Additional guidance

Core objectives

The following seven core objectives apply to all investigations.

It is not necessary to formally record them every time, although you may choose to do so. The core objectives will be SMART provided adequate resources are made available and realistic deadlines are set.

Identify the relevant dutyholder(s) and witnesses

This should be a priority objective, as dutyholders need to be identified as soon as possible so that intelligence can be gathered in the preparation stage.

Possible enforcement action and responsibility for any remedial action will also need to be correctly targeted at the responsible dutyholder(s).

Witnesses need to be identified quickly so that information can be obtained to inform the early stages of the investigation

Establish the key facts relating to the causes of the incident

Guidance and training are currently being developed covering methods and tools that can help the investigation establish the sequence of events, and so deliver this objective.

Identify immediate and underlying causes

The following definitions of immediate and underlying causes apply:

In the example of the vehicle fracturing the pipe, underlying causes might include:

Guidance and training are currently being developed covering investigative methods and tools that can help deliver this objective.

Identify any lessons learned

Lessons learned are the findings from an investigation about measures needed to prevent further similar incidents based on what went wrong (key facts) and why (underlying causes). These lessons should form the basis of any recommendations for remedial action.

Lessons can be extracted from any aspect in the chain of events to offer valuable learning. However, lessons that address underlying rather than immediate causes will usually offer a sound basis for action to prevent recurrences. The lessons learned may also have wider implications, beyond the dutyholder directly involved.

Ensure appropriate remedial action is taken to prevent a recurrence

You need to be clear about exactly what is to be achieved and by whom.

To ensure remedial action will prevent a recurrence you should be satisfied that underlying causes are addressed. You should also consider how far any findings should be shared/acted on.

Appropriate remedial action may involve:

Direct remedial action with dutyholder(s) involved in the investigated incident

The dutyholder(s) would normally be responsible for implementing remedial action at the site of the incident and on other sites they may operate.

Ensuring remedial action is taken may involve influencing dutyholder(s), monitoring progress and/or perhaps taking enforcement action

Wider remedial action to ensure, where appropriate, that action is taken to prevent a recurrence more widely. This may involve sharing learning, influencing action to be taken, and monitoring progress of action delivery:

Remedial action may involve a long-term commitment, for example involving significant capital investment or complex management of change. Where such longer-term action is involved you may wish to close the investigation and establish follow-up action, in line with step 4.12 of the investigation procedure.

Identify the relevant law and whether there are any breaches

This objective focuses on identifying relevant legislation and determining whether there has been a breach.

For goal setting legislation it will be necessary to identify the relevant standards/benchmarks against which the dutyholder(s) can be measured to determine whether there has indeed been a breach.

The priority you give this objective will depend on the nature of the incident and it may change as the picture of what happened emerges.

Form a view about appropriate further action using the EMM framework

With the relevant law and any breaches identified, this objective requires that a decision be taken using the Enforcement decision making procedure on what, if any, enforcement action is required.

This will include any action considered necessary in order to control a risk of serious personal injury, or to secure the delivery of improvements to prevent a recurrence.

Where enforcement action is required, you should follow the relevant OG wide procedures.

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Updated 2015-12-15