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Investigation process

The purpose of SHK investigations

SHK's investigations are intended to clarify, as far as possible, the sequence of events and their causes, as well as damages and other consequences. The results of an investigation shall provide the basis for decisions aiming at preventing a similar event from occurring in the future, or limiting the effects of such an event. The investigation shall also provide a basis for assessment of the performance of the rescue services and, when appropriate, for improvements to these rescue services. When appropriate, SHK shall also issue recommendations regarding relevant measures to take to enhance safety.

SHK does not have any regulatory or supervisory role and its investigations do not deal with issues of guilt, blame or liability for damages. The sole objective of the investigations is safety.

The investigation team

SHK investigation teams always consist of at least a chairperson (a former judge) and an investigator in charge. Often other investigators with different specialist skills are also a part of the investigation team.

Considering the vast range of occurrences that may come under investigation, it is evident that SHK often also needs to engage external experts in various fields.

A representative of the regulating authority concerned is normally invited to follow the investigation, however without being a part of the investigation team.

Fact-finding presentation meeting

At the end of the fact-finding phase, SHK holds a fact-finding presentation meeting, where all the facts so far are presented. All concerned parties are invited to take part in this meeting.

A report of the investigation is always published on SHK's website.

Investigation process in short

  • Registration of an occurrence report
  • Initial analysis of the occurrence
  • Chair of investigations decides to investigate or not
  • Appointment of the investigation team
  • On site visit
  • Start-up meeting
  • Investigation plan and budget
  • Fact-finding phase
  • Work and follow-up meetings with investigation team
  • Fact-finding presentation meeting for stakeholders
  • Analysis and report drafting phase
  • Draft report is circulated for internal consultation
  • Draft report is circulated for external consultation
  • Finalizing of report
  • Final report is published
  • Follow-up to safety recommendations


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