PROCESS 3.1.5 INVESTIGATION.

Performance Objective. The organization will establish procedures to collect data and
investigate incidents, accidents, and instances of potential regulatory noncompliance to identify potential new hazards or risk control failures.
Design Expectations.
(1) The organization will collect data on:
      (a) Incidents,
      (b) Accidents, and
      (c) Potential regulatory non-compliance.
(2) The organization will establish procedures to:
     (a) Investigate accidents,
     (b) Investigate incidents, and
     (c) Investigate instances of potential regulatory non-compliance.

Investigations  Investigation of safety occurrences should have the objective of identifying systemic safety deficiencies (poor system design, failed controls, failed preventative/corrective actions, etc.) rather than assigning blame. It is not as important to identify who did it as it is to learn why it happened. 
System resilience can be much more effectively reinforced by removing systemic deficiencies than by removing individuals, who may only be caught in the human activity of making mistakes.

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