Incident Investigation Report

This article provides a comprehensive overview of the importance of conducting Incident Investigations and the key elements that make up an effective report. Understanding the process of investigating incidents and documenting findings is crucial in preventing future occurrences and ensuring workplace safety. This article serves as a guide for individuals and organizations looking to improve their incident investigation processes and produce effective reports.

Administrative Content

• Cover page
  

  • Accident title and date

  • File index number

  • Name of Company concerned

• List of Contents

• Investigation Process
  

  • Investigation Team Members and Roles

  • The mandate given to the Investigation Team

  • Description of the investigation process incl. timing and methods used, e.g. investigation methodology, meetings, interviews, re-enactment, etc.

Executive Summary

• Brief description of the event, its consequences and the main conclusions of the investigation.

Facts about the Accident

• Facts in chronological order

• Description of sequence of events

Emergency Arrangements

• Evaluation of the effectiveness of any emergency response activities

Findings

• Description of findings and observations made by the investigation team

Consequences of Incident

• Describe immediate and any long term

Controls in Place Relevant to the Accident

• Procedures, instructions, training and organizational issues

• Technical barriers incl. detection and alarms

Causes of the Accident

1.Immediate causes

• unsafe actions
  

  • communication

  • use of tools and equipment

  • use of protective methods

  • inattention/lack of awareness

• unsafe conditions
  

  • protective systems

  • transportation, equipment, and tools

  • work exposure

  • workplace environment/layout

2.Underlying causes

• human factors
  

  • physical capabilities

  • physical conditions

  • mental state

  • mental stress

  • conduct

  • skill level

• workplace factors
  

  • training/knowledge transfer
    

    • management/supervision/employee leadership

    • contractor selection and oversight

    • engineering design

    • work planning

    • purchasing, material handling, and material control

    • tools and equipment

    • work rules/policies / standards/procedures 

    • communication

3.Management system failures

• leadership

• risk management

• strategy and planning

• people and competency

• asset integrity management

• procedures

• contractor and supplier management

• operating responsibility

• crisis and emergency response

• performance and assurance

Incident Causation Matrix Tool

Conclusion about Incident

• Investigation Team Leader’s conclusions incl. descriptions of reasoning and references to Event Trees, Interviews, Observations, Technical findings etc.

Recommendation

• Include details of what, who, when and any verification requirements e.g. audit.

• Distinguish between organizational items (e.g. training), technical items (e.g. modifications) and management systems (e.g. procedures and policies)

• Immediate (remedial action that will temporarily maintain safety integrity)

• Short-term (preventive action that can be executed at short notice)

• Long-term (preventive action involving long lead items or processes)

• Similar Events, if any

Attachments

Incident Scene:

• Photos;

• Videos;

• Drawings;

• Plans;

Technology:

• Equipment Certificates;

• Data sheets, technical documents

Organization:

• Toolbox Cards;

• PTW;

• Isolation;

• SOP;

• Procedures;

• Miscellaneous Registers (PTW, Isolation, Drops etc.)

• Environment

People

• POB;

• Statements, interview transcripts etc;

• Personnel Certificates;

• Training Records;

• Fitness to Work;