1.2 How to implement an Event Investigation process

1. Select a manager/department to be responsible for the process.
   
   
2. From the very beginning, ensure that the program is a cooperative endeavor of labor, management and, if appropriate, the regulator.
   
   
3. Select an investigation process that systematically determines the contributing factors of events, and on the basis of these findings, develop and monitor a comprehensive fix.
   
   
4. Write the policies and procedures needed to implement the event investigation process.
   
   
5. Consult applicable guidance on voluntary reporting systems such as the FAA’s Aviation Safety Action Program (ASAP).
   
   
6. Develop and implement a reasonable, consistently applied company disciplinary policy.
   
   
7. Identify screening criteria to determine which events will be investigated.
   
   
8. Select and train all investigators in a consistent manner to minimize interpretation differences later. Invite/encourage regulators to attend such training sessions.
   
   
9. Communicate with management and workforce about the event investigation process to obtain their input and buy-in.
   
   
10. Establish a team to review the investigation findings and to select areas for improvement.
    
    
11. Follow up to ensure that needed improvements are being made.
    
    
12. Inform all personnel on the status of improvements in progress. Use newsletters, company/labor websites, crew meetings, and posters to demonstrate and remind everyone that the process is working and somebody is actually tracking the progress.
    
    
13. Create a database for documenting investigation information and measures of change. Events and contributing factors should be classified according to a standardized system so that data can be analyzed, summarized and trended. Examples of existing classification tools include Maintenance Error Decision Aid (MEDA) and Human Factors Analysis and Classification System—Maintenance Extension (HFACS-ME).
    
    
14. Use risk assessment techniques to quantify specific event likelihood and severity.
    
    
15. Evolve the system to include reporting of potential events that are also called threats.