A six-step, structured approach to incident investigation helps to ensure that all the causes are uncovered and appropriate remedial action taken. Step 1 - Immediate action
In the event of a serious incident, immediate action may include:
•Making the area safe
•Preserving the scene
•Notifying relevant parties e.g. HSE, Agility, British Gymnastics
•Collecting perishable evidence, e.g. CCTV tapes, samples. Step 2 - Plan the investigation
Planning ensures that the investigation is systematic and complete. Consider:
•What resources are required?
•Who will be involved?
•How long will the investigation take?
For severe or complex incidents, an investigation team will be more effective than a single investigator. Step 3 - Data collection
Information about the incident is available from numerous sources, not only people involved or witnesses to the event, but also from equipment, documents and the scene of the incident. Step 4 - Data analysis
Typically, an incident is not just a single event, but a chain of events. The sequence of events needs to be understood before identifying the root and underlying causes for the accident as well as the direct, more obvious causes. Although the action or errors of one person may be the direct cause, the root/underlying causes are usually traced back to the environment and management approach in respect of people, resources and finance and health and safety. Step 5 - Corrective actions
It is important that the remedial actions deal with both the direct causes (often a quicker fix) and the root and underlying causes. It is important not to miss an opportunity to reduce the risk of recurrence of this or a similar type of incident with a common root cause. Step 6 - Reporting
The investigation is concluded when all actions have been completed and the findings have been communicated to relevant people so that lessons can be shared. This can be achieved by providing information at relevant meetings and developing scenarios to use in presentations and training for club staff and volunteers. If you have learned something that might be relevant to a wider gymnastics audience, please also share this with the health and safety team at British Gymnastics by emailing: [email protected]