FOR AN ACCIDENT reporting and investigation process to achieve its goal of improving safety, it's no good simply collecting and disseminating information; you need to learn from the accident if you are to avoid a repeat. Experts have come up with various models for accident analysis -- Frank Bird's accident triangle, Jim Reason's Swiss cheese -- but whatever approach you take to accident management, the most important steps remain the same: you need to investigate the incident, identify immediate triggers and root causes, and review control measures. Failing to use your reporting system to learn from accidents -- by first investigating them and then taking any necessary remedial action (replacing equipment, re-training or simply enforcing an existing procedure) --is as much use as conducting a risk assessment and filing ii in a drawer. You might have ticked a legal box, but you won't have reduced risks.
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