A formalized root cause analysis process is used to identify the root causes of incidents and near misses. The incident investigation teams include personnel with relevant knowledge. All operations personnel receive introductory training in incident investigation, while supervisors and team leaders receive advanced training. Near misses and errors are encouraged to be self-reported without punitive action. Root cause analysis produces recommendations to address systemic problems, which are evaluated and tracked. A lessons learned program captures information to improve safety and effectiveness, and disseminates lessons learned. Lessons learned are summarized and shared in a timely manner, and follow-up monitoring assesses implementation and effectiveness.