A Safety Management System attempts to prevent harm from arising in the conduct of normal
operations. Sometimes, however, in spite of the best intentions, occurrences do happen. While
their consequences may vary, they afford an opportunity to learn and put in place the needed
process repairs and/or system reforms to make things better.

• understand the events leading up to the occurrence;
• Identify causal and contributory factors (active and latent factors);
• Make recommendations to eliminate unacceptable hazards and/or reduce their risks;
• Communicate the Module learned broadly.