ABSTRACT
Causal factors, root causes, and recommendations should be presented in a manner that clearly shows the connection between each of these levels of the investigation. A standard method for presenting a relationship is a table with the causal factors in the first column, the root causes in the second column, and the recommendations in the third column. Fault trees or 5-Whys trees and causal factor charts can often save the investigator additional writing by providing a summary of the incident, including what happened, when it happened, who was involved, and how it happened. In addition to recommendations to communicate the investigation results to those who are affected by the corrective actions, it is also important that those personnel who assisted the investigation team be made aware of the investigation results. Tracking recommendations should continue until implementation of all the recommendations is complete.
