Incident investigation - learning lessons

We carry out investigations to prevent the same or similar incident from happening again. This page provides guidance on how to communicate the recommendations from incident investigations.

What are lessons learnt?

The investigation will have addressed the following questions:

What was the immediate cause – what went wrong
What was the underlying cause – why it went wrong
Were there any aggravating factors – what made the likelihood that it would happen greater or made the consequences of the incident worse than they may have been in a different situation
Were there any mitigating factors – what made the likelihood that it would happen less or made the consequences of the incident less severe than they could have been

The investigation will have also considered the control measures:

Were they sufficient?
Can they be improved?
Were they necessary?
Are new control measures needed and if so what are they?

The summary report that shares these conclusions and recommendations is called the Lessons Learnt report.

How to communicate the investigation findings

The content of the Lessons Learnt report will depend on the incident and every report will be different but some general guidance is below.

Keep it simple – this is not an investigation, consider what information you would need to know to ensure that the same incident did not happen again rather than all the information needed to understand why the incident happened
Best practice needs to be communicated – investigations look at mitigating factors, human error will happen so it is important to tell people what worked to lower the consequences as well as telling them what went wrong
Knowing what not to do can be as important as what to do
Be clear and specific – everyone knows to review the risk assessment and the associated SOPs after an incident, however the report should cover what needs to be looked at and whether changes should be made or why a particular section of the risk assessment or SOP needs review

Who to communicate the investigation findings to

The lead investigator will recommend who to share the Lessons Learnt report with. This should be agreed with the Head of Department as the Chair of the Departmental Safety Committee and specialists from Safety Services or the Fire Safety team when relevant. The Departmental Safety Officer may also be consulted.

UCL recommends the following groups are considered.

The Injured/Involved Person (IP) – to ensure a positive and inclusive safety culture the report should be shared with the person who made the initial incident report and any people involved who were not part of the investigation
The Departmental Safety Committee
The Appointed Person group – when an incident involves the following hazards, the report must be shared with the relevant groups as listed within the departmental Responsible Persons Register in riskNET such as
- CL3 lab managers
- Fire marshals
- First aiders
- GM safety officers
- Radiation protection officers
- Laser safety officers

The lead investigator will also consider recommending whether the report should be shared with the following groups.