by HSEI Training
You’ve just finished your onsite investigation, collected and reviewed all the data, established the facts, identified the contributing factors, and formulated recommendations to reduce risk and prevent recurrence. What now? It’s time to prepare and develop your investigation report - the formal presentation of the investigation team’s findings and recommendations.
What's the objective of the Investigation Report?
The objective of an incident investigation report is not only to be able to report accurately on the incident facts, incident mechanism and the contributing factors, but to also demonstrate that the investigation has been conducted in a professional manner.
Writing the Report
The report should be written in a clear, concise, logical, and readable format. Remember that some of the people reading the report or making decisions on the recommendations may not have relevant operational experience or a similar technical background, so keep the language simple and straightforward. Write the report in such a manner that a anyone within the organization could read the report and basically understand it.
Format of the Report
While the format and contents of the investigation report differs dependent on each organization’s protocols, as a minimum the report should include the following sections and meet the quality standard indicators as listed below:
Incident description
Date/time/location
Details of injuries/damage to equipment/environmental impact/impact on production or operations
Risk rating (actual and potential consequence)
Photographs
Timeline/sequence of events
The incident description - this should be a statement of the facts immediately surrounding the incident, covering the period from the initiating events until the situation was under control and identifying, where possible, the equipment and people involved following the sequence of events
Key Findings
Outlines why the incident occurred
Contributing factors identified from the investigation are categorised using the organization’s analysis method
Conclusions and Observations
Are presented in brief statements that:
Include the conclusions drawn from the analysis of the findings
Highlight at least one finding per conclusion
Are organized sequentially, chronologically or in in logical sets
May include issues to do with the reporting culture, previous incidents or the effectiveness of the rescue and damage containment where appropriate
Recommendations
Address all contributing factors
Have a direct link back to the incident, target risk reduction, and prevention of recurrence
Are based on the hierarchy of controls
Accountability/responsibility is established
Time schedules for implementation are included
Significant Learnings
Generic learnings for the organization from the investigation are identified
Covers issues that if corrected should prevent similar incidents elsewhere within the organization or within the industry
May address positive findings such as risk controls that were effective during the incident sequence
Analysis Graphical Representation / Chart
Graphical representation is included of the analysis methodology used to identify the key circumstances and factors relating to the incident
Outlines the relationship of the various elements considered throughout the report
Assists in assuring the investigation followed a logical path
Provides a diagrammatic display of the investigative process for management briefing
Corrective Action Plan
Contains the following information:
Recommendation
Responsible Department
Responsible Person
Planned date for completion/implementation
Actual date completed/implemented
Sign off when completed
Executive close out of incident verifying that all corrective actions have been fully implemented
Comments (as required)
Report Sign-Off
To maximize the preventative potential of the investigation report, the findings and conclusions of the report should be distributed to the various stakeholders involved in the incident and as widely as practicable. This section should include the following report sign-off sections:
Feedback to the Involved Person(s) and comments
Feedback to Involved Supervisor(s) and comments
Department Manager’s acceptance of findings and comments
Risk Manager’s acceptance of findings and comments
Safety Manager’s acceptance of findings and comments
Senior Management’s acceptance of findings and comments
General Recommendations
The following should be considered when preparing an investigation report:
The report should be factual, concise, and conclusive.
Interpretations of findings should be based on the facts as identified during the investigation
Assessment of basic cause should be based on the analysis of the findings
Events or conditions that are major contributing factors to the incident should be clearly identified as such
The report should be readable as a stand-alone document – references to other documents not open to inspection by others should be avoided
Strict document control procedures should be in place
Reference to all documents and records relevant to the incident should be established
Conclusion
Always strive to document a factual, timely, and thorough investigation in a clear, complete, and concise report. Keep in mind that the presentation of a logical and structured incident investigation report has two primary aims:
Ensuring that the reader understands all the factors pertinent to the specific incident under investigation, and
Ensuring that the recommendations achieve the goal of prevention of recurrence
Organizations should develop a quality standard for their internal incident investigation reports. This not only assists the Investigator in ensuring they include all required information, but acts as a guide for approving stakeholders to ensure that reports are of a standard that meet all the requirements and are accepted and approved.
Interested in Knowing More?
Further information on HSE International’s ICAM training is available from our website: https://www.hseigroup.com/icam.