Investigation process

From notification to publication of report 

1. The Norwegian Safety Investigation Authority (NSIA) has a 24-hour emergency response service and receives notification from, for example, the police, the Joint Rescue Coordination Centre (JRCC), the organisations or companies involved or others, in the event of a serious incident or accident. The NSIA also receives written reports of incidents or accidents that fall within its areas of responsibility. 
 
2. The NSIA considers whether to deploy personnel to document the accident site and secure information.

3. The NSIA then considers whether a safety investigation should be initiated. For some accidents, there is a duty to investigate, while the decision to investigate other accidents or incidents is based on a discretionary assessment. When considering whether to investigate, we take into account factors such as the severity of the accident, the possibility of improving safety and the expected learning potential.

4. We inform relevant stakeholders that we are launching a safety investigation and publish information about this on our website.

5. An investigation normally starts with collecting a broad array of information. During the investigation, the NSIA will continuously assess which areas should be investigated further and to what extent.

We interview a range of people who may have information of relevance to the investigation. This ranges from those directly involved in the accident, to witnesses, next of kin, people at different levels in the affected companies or organisations, manufacturers, trade associations and various expert and administrative authorities in Norway and abroad. More about interview here.

Our investigations may involve:

• a review of large quantities of information relating to technical and operational matters
• a mapping of the organisations’ or companies’ requirements for expertise, procedures for training and maintaining the required level of expertise
• a review of the relevant companies’ organisation, internal regulations, duties/responsibilities, access to resources and safety and quality procedures
• a mapping of framework conditions, technical standards, design specifications, legislation, regulations, current supervisory activities etc.

Each case is unique, and what is investigated and the scope of the investigation will therefore vary according to the incident or accident in question. 

Investigation activities, such as on-site inspections and technical reviews with manufacturers and suppliers, often take place in collaboration with other countries’ investigation authorities and the stakeholders involved. If we need increased expertise in an area, we will draw on necessary external assistance, both nationally and internationally.

If we make safety-critical findings during the investigation, we will notify the relevant stakeholders as soon as possible to enable measures to be taken. Information about this will also be published on our website.

The NSIA’s report after the accident or incident may include recommendations for the purpose of improving safety. These safety recommendations may concern technical, organisational or system-related conditions and be addressed to the relevant authorities and/or stakeholders.

6. Those contributing information to the investigation will usually receive a draft report for review. The purpose is to verify the factual information used in the investigation. The NSIA will make an assessment of whether to send the whole report or only those parts of the draft that a particular party, owing to their connection to the case or investigation, is particularly qualified to comment on.

The draft report is exempt from public disclosure. One of the reasons for this is that there are often several parties involved in an investigation, and their information about or experience of the case will often differ. It is only when the information is compiled into a draft that they have the opportunity to see it in context, and thus provide views or new information if relevant.

The NSIA reviews the comments received and decides what should be included in the final report. If we receive new and crucial information, it may be necessary to conduct new investigations.

7. Finally, the final report is sent to the relevant ministry or agency with follow-up responsibility, with a copy sent to the parties involved. The report is then published on our website.

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What is not part of the NSIA’s social mission? 

The NSIA has no supervisory duties. It is not the NSIA’s task to apportion blame or liability under criminal or civil law, which means that this is neither investigated nor described in the report. The NSIA’s investigations shall be conducted independently of other investigations or inquiries wholly or partly conducted for different purposes. This means that parties involved with an interest in the criminal or civil law aspects of an accident or incident must carry out their own investigations or inquiries, and that they cannot rely on the NSIA’s safety investigation and report. 

Any use of the report or information obtained in the course of the investigation for purposes other than preventive safety work will undermine the NSIA’s remit and is detrimental to safety work.