6.1 Introduction

Recommendations are the most important product of an investigation. In addition to addressing the causal factors for an incident, recommendations should also address system improvements aimed at the root causes of the incident.

Recommendations are developed after the analysis of data and the identification of root causes (if performed as part of a root cause analysis) are completed.

This section describes the characteristics of effective recommendations, the timing of recommendation implementation, the four levels of recommendations, and the four types of recommendations. In addition, methods to format, assess, and prioritize recommendations are also covered in this section.

Figure 6.1 shows this step within the context of the overall incident investigation process.

Figure 6.1: Developing Recommendations Within the Context of the Overall Incident Investigation Process

Recommendations should be directly tied to causal factors and their underlying causes, as shown in Figure 6.2. Implementing a recommendation should eliminate the causal factor and the underlying root causes that caused the loss event. Therefore, implementing recommendations should inhibit and disrupt the sequence of events that led to the loss event. As a result, it should prevent recurrence of the incident and its underlying causes.

Figure 6.2: Connecting Root Causes and Recommendations

The only recommendations that help the organization are those that are actually implemented and eventually proven to be effective. Therefore, recommendations must be practical, feasible, and achievable. What is practical, feasible, and achievable can vary significantly from organization to organization and from industry to industry. Different organizations and industries have different...