The primary goal of investigating an incident is to prevent future incidents from happening.
Ask yourself the right questions
The Five W’s - According to the principle of the Five Ws, a thorough investigation must answer these 5 questions: WHO, WHEN, WHERE, WHAT, and WHY.
- WHO - List all parties involved, including witnesses. (This will not be visible to the public)
- WHEN - Date and time of the incident.
- WHERE - Location of the incident.
- WHAT - Describe in detail what happened. Use chronological order if possible.
- WHY - List all possible contributing factors including the root cause that gave rise to the incident.
How to uncover the root cause of the incident
Ask WHY at least 5 times…This technique is called FIVE WHYS. The method is remarkably simple: ask "Why?" at least five times. The goal is to reveal the root cause of the incident. One of the 5 answers will usually reveal the root cause.
Here is an example: I had a hard landing and I broke my leg.
Using the FIVE WHYS technique to help uncover the root cause:
- Why was my landing so hard? I stalled the wing while trying to land.
- Why did the wing stall? The brake inputs were too strong and aggressive.
- Why was I using aggressive brake inputs? The wing was pitching due to gusty conditions.
- Why was it so gusty? I was flying in strong midday conditions.
- Why was I flying in those conditions? I wasn't aware of the risks of midday flying.
This 5th question reveals the root cause of the incident. Understanding the root cause will allow you to share what can be learned from the incident and more importantly what actions can be taken to prevent a similar incident from happening again or to someone else.
Avoid making assumptions
Beware of confirmation bias - “The confirmation bias is a cognitive bias that causes people to search for, favor, interpret, and recall information in a way that confirms their preexisting beliefs.” If you approach the incident, believing that you already know how/why it happened, you may be blind to any evidence or clues that run contrary to the belief you have already formulated in your mind. Revisit the entire sequence of events with a blank slate. Perhaps you'll uncover more causal factors that you weren't aware of. Maybe the how/why will be different from what you originally thought.
Seek multiple perspectives
When possible, talk to multiple people to get various perspectives. Memory is a funny thing…it’s easy to get the details wrong. It’s best if we can hear from multiple witnesses while gathering the key findings and writing the report.
Analyze the contributing factors that caused the incident
Analyze the contributing causes of the incident. Remember that the incident is likely to have been caused by a number of factors that have several contributing causes and conditions. Try to list as many causal factors as possible. What were the other contributing factors? Weather? Location? Gear? Skill level? Poor judgment? Etc. Incidents rarely have one cause. It’s almost always a combination of several things that give rise to the incident. Try to identify as many as you can.
Summarize your findings and suggest safety procedures
Use the Incident Report Form to share as many details as possible about the incident. You can summarize your findings, share what can be learned from the incident, and suggest what actions can be taken to prevent a similar incident from happening to someone else.