Through an investigation, we acquire facts and identify causes. On that basis, we assess which reactions are required to bring the activity into compliance with the regulations and to prevent similar incidents.
When do we investigate?
Incidents which typically qualify for direct investigation by us include:
- major accidents or near misses of major accidents
- fatalities related to accidents at work
- serious personal injuries with a potential to cause death
- serious weakening or loss of safety functions and barriers, which threatens the integrity of the facility.
Our response to a serious incident can take the following forms:
- conducting our own independent investigation, often in parallel with inquiries pursued by the public prosecutor backed by our technical support
- checking the operator’s system for following up the incident
- assessing the operator’s own investigation reports.
Where necessary, an investigation can be conducted in collaboration with other regulatory agencies.
Key role in supervision
Following up incidents forms part of the regulatory concept, and represents an important part of our supervision. Experience from these investigations is used for such purposes as:
- prioritising supervisory activities
- informing/briefing the industry to ensure experience transfer
- assessing the need for regulatory changes as well as for continued development of the regulations and the way we conduct our supervision
- enhancing our own expertise.
Investigations represent a good way of identifying the causes of serious incidents and focusing attention on causal mechanisms – human, technological and organisational.