The Lead Investigator is responsible for coordinating the investigation into any event that is considered to be a learning opportunity or that is required by regulation. This includes understanding the context of the system actions leading up to the event, identifying recommendations to mitigate any adverse findings or promote any good practice findings, and communicating the safety messages to the appropriate stakeholders.
The sole objective of an investigation is to learn and to identify opportunities to strengthen the system such that similar events are prevented. There is no value in apportioning blame or liability and as such the Lead Investigator shall NOT judge the contribution of those individuals involved in the event.
The following material provides guidance to support this role.