A useful strategy for approaching a Final Report is to read the Executive Summary first, then skip to the end to read the Safety Issues, Findings and Recommendations. After that, if you need, tackle the parts in between.
The principal purpose of a report is to set out the circumstances and causes of a maritime, aviation and rail accident or incident, with a view to avoiding similar occurrences in the future. It includes information necessary to support the Commission’s Analysis, Findings and Recommendations. While Commission Reports do not ascribe blame, they do not avoid setting out what happened.
- The Commission, its status and the commissioners who produced the Report
- Notes on what can and can’t be done with the Report, and who owns it
- The Verbal Probability Table sets out what the Commission means with phrases like ‘Virtually certain’ and ‘highly unlikely’
- A photograph of the accident scene or vehicle and a map of the location
- A glossary listing key specialist words and phrases used in the Report
- A data summary setting out
Executive Summary: the key points from all sections of the report, written for a non-technical reader to easily understand.
Conduct of the Inquiry: broadly outlines the process the Commission followed throughout the inquiry, including key milestones in the investigative and inquiry phases.
Data Summary: a quick reference to key factual information – for example, about the vehicle involved, the route taken, and other technical details.
Factual Information: a narrative of 'what: happened and anything else readers need to understand the "why" set out in Analysis section that follows, and the Findings made.
Analysis: discusses the facts. It reflects the Commission’s views on the factors that contributed (or not) to the occurrence. Various proposed explanations may be discussed, based on the evidence, that lead to Findings, Safety Issues, and Recommendations.
Findings: Highlights the Commission’s key Findings -- information uncovered through the investigation, relevant to the Commission’s purpose of explaining the circumstances and causes.
Key Safety Issues: safety issues detailed here may be general rather than particular; that is, they need not have contributed to the occurrence that prompted the particular inquiry. If the Commission determines that a safety issue has serious implications for transport safety, then it will make Findings and Recommendations to address them, irrespective of whether they were contributory.
Safety Actions: the actions stakeholders have already taken to address Key Safety Issues, covering matters for which Recommendations would otherwise have been issued.
Recommendations: If Safety Issue have not yet been addressed, then the Commission makes a Recommendation for an appropriate recipient to take action. The Report notes any responses received prior to publication, while later responses are added to the website record.
Key Lessons: Broader learnings arising from the inquiry that can be more generally applied or considered within the sector to help prevent similar events.