Sch 6 para 4 Analysis and conclusions
(1) Final account of the event chain— establishing the conclusions on the occurrence, based on the facts established in paragraph 3 . (2) Discussion— analysis of the facts established in paragraph 3 with the aim of drawing conclusions as to the causes of the occurrence and the performance of the rescue services. (3) Conclusions— direct and immediate causes of the occurrence including contributory factors relating to actions taken by persons involved or the condition of rolling stock or technical installations; underlying causes relating to skills, procedures and maintenance; root causes relating to the regulatory framework conditions and application of the safety management system. (4) Additional observations— deficiencies and shortcomings established during the investigation, but without relevance to the conclusions on causes. (5) Measures that have been taken— Record of measures already taken or adopted as a consequence of the occurrence. (6) Recommendations.