So, you’ve finished your on-site 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 your written investigation report. The investigation report is the formal presentation of the investigation team’s findings and recommendations.
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, 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 technical background, so keep the language simple and straightforward (remember - no TLA’s… three letter acronyms or technical jargon). Write the report in such a manner that a layperson 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 organisation’s protocols, as a minimum the report should include the following sections and meet the quality standard indicators as listed below:
Date / Time / Location
Details of injuries / Damage to equipment / Environmental impact / Impact on production or operations
Risk rating (actual and potential consequence)
Timeline / Sequence of events
The incident description 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 and follow the sequence of events.
Conclusions And Observations
Are presented in brief statements that:
Include the conclusions drawn from the analysis of the findings.
Highlight one finding per conclusion.
Are organised sequentially, chronologically or in in logical sets.
May include issues to do with the reporting culture, previous incidents or timeliness of the investigation or the effectiveness of the rescue and damage containment where appropriate.
Address all contributing factors.
Have a direct link back to the incident and target risk reduction and prevention of recurrence.
Are based on the Hierarchy of Controls.
Accountability / responsibility is established.
Time schedules for implementation are included.
Generic learnings for the organisation from the investigation are identified.
Covers issues that if corrected should prevent similar incidents elsewhere within the organisation or within the industry.
May address positive findings such as risk controls that were effective during the incident sequence.
Appendix A - 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 diagrammatical display of the investigative process for management briefing.
Appendix B - Corrective Action Plan
Contains the following information (usually in a table format):
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 (or reasons given if recommendations are not adopted).
To maximise the preventative potential of the investigation report, the findings and conclusions of the report should be distributed to the various people 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 Person/s Supervisor/s and comments
Department Manager’s acceptance of findings and comments
Risk Manager’s acceptance of findings and comments
Safety Department / Manager’s acceptance of findings and comments
Senior Management’s acceptance of findings and comments
The following should be considered when preparing an investigation report:
The report should be factual, concise and conclusive.
Interpretations or 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 (i.e. the general public) should be avoided.
Strict document control procedures should be in place.
Reference to all documents and records relevant to the incident should be established.
Remember, strive to document your factual, timely and thorough investigation in a clear, complete and concise report. Keep in mind that the presentation of a logical, structured incident investigation report has two primary aims a) ensuring that the reader understands all the factors pertinent to the specific incident under investigation and b) ensuring that the recommendations achieve the goal of prevention of recurrence.
Organisations should develop a Quality Standard for Incident Investigation Reports. This not only assists the Investigator in ensuring they include all required information, but acts as a guide for Approving Officers 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 Safety Wise’s Incident Cause Analysis (ICAM) Training is available from our website: http://www.safetywise.com/
Additional ICAM Related Services
Safety Wise also offers the following additional services for sites that adopt the ICAM investigation analysis method:
Quality review of incident investigations using ICAM
Trend analysis of organisational factors contributing to serious incidents
Participation in investigations as an external / independent party
ABOUT THE AUTHOR- Jo De Landre (Executive General Manager)
After 15 years with the Bureau of Air Safety Investigation (BASI),which became part of the multi-modal Australian Transport Safety Bureau (ATSB), Jo started co-facilitating ICAM training with Safety Wise in 2001 as the Principal Human Factors Consultant.
In 2005, Jo was promoted to the position of Executive General Manager of Safety Wise and beyond providing human factors specialist services and ICAM training and Investigations, she is now involved in strategic activities such as project management and developing safety management programs.
Jo has been the Safety Wise Lead Investigator for many high profile accidents, including multiple fatality investigations. She has a Bachelor’s Degree in Applied Psychology and a Graduate Diploma of Psychology, and has published papers in aviation, mining and police journals and publications.
Joanne has also been Secretary of the Australian Aviation Psychology Association (AAvPA) for close to a decade.