karen wrote:Um read the report as it includes a timeline of how and why it took so long.
Let's put this in perspective shall we ...?
The report into the 1988 Piper Alpha incident took 16 months from start to finish. Highly complex and technically challenging with more expert testimony than you could shake a stick at. 2 x volumes of over 1000 pages accompanied by drawing, line diagrams and P&I drawings. Take a look at the timeline for this report if you want to see how it should be done.
Coming from an industry where incident investigation and the implementation of lessons learned is critical, I repeat my earlier dismay that it takes a year to produce a semi-detailed report into a simple event such as the Kingsbury incident.
NRA / MoD really ought to consider hiring an impartial, specialised incident team who would conduct any such investigations into firearms incidents as required. There are plenty of highly-skilled and experienced personnel out there who are perfectly capable of establishing the immediate / root causes of these events. Just give them a mandate, a decent budget and a time-frame for when you want the report finalised and they will do the rest. It really is as simple as that.
NRA and MoD really need to leave things like this to people who actually know what they are doing. Their only input (other than answering pertinent questions from the SME) should be to act on the incident report findings. Only then will we see reports completed in a timely manner.
Let's not lose sight of why we conduct these investigations. It's NOT to point the finger at anyone but only (repeat) only to ensure we can learn from the incident circumstances and prevent a recurrence. Therefore, time is crucial! Other people may be out there and seperated from a similar incident by as little as a single trigger pull, so let's investigate efficiently and get the information out quickly. Morally, we have a duty to do that if nothing else.
Typical reporting regime for my industry is as follows:-
Flash report within 2 hours
Initial report within 24 hours
Full report within 30 days (completed with all inspection data)
Mezzer (sent from the NW England station)
