After completing this topic, you should be able to
[Topic title: Investigation Reporting.] Once all the data gathering is complete, the final stage of an incident investigation involves completing a report and submitting it to the proper company authorities. Regardless of the type of incident, there are four key elements that must be included in an incident report. One of them is necessary background information on the incident.
Background information includes where and when the incident happened, what task or activity was going on, what people and equipment were involved, and the identity of operating personnel and other witnesses.
The next element of the incident investigation report is the account of the incident. The purpose is to determine what happened – the sequence of events, the extent of the damage, the incident type, and the source of energy or hazardous material.
The third element of the incident report, discussion, includes an analysis of how and why the incident occurred. The discussion section details the direct cause, such as energy sources or hazardous materials; the indirect cause, such as unsafe acts and conditions; and the root cause, such as personnel and environmental factors.
A key purpose of incident investigation is to prevent similar incidents in the future. So the final element – the recommendations section – of an incident report is very important. This section contains recommendations for short-term and long-term actions that can be taken to prevent a recurrence.
These recommendations should address the root causes, such as an outdated procedure; the indirect causes, such as failure to follow correct procedures or work practice; and the direct causes, such as improper protective equipment for the specific hazardous materials.
Occasionally, a report may need to be extended to include a cover page and title page, names and signatures of investigation team members, and a table of contents. It may also include an abstract, commentary, and discussion of probable causes. In addition, the report can include conclusions, recommendations, and an appendix or attachments. Investigators can make use of special report forms, which are available in many cases.
Additionally, any information or evidence uncovered during incident investigations that would be of benefit in developing a new regulatory standard or in modifying or revoking an existing standard should be promptly transmitted to the applicable labour authorities.
It's important to remember that an incident report is not considered complete if any of the four key elements are missing.
With that in mind, let's pause here to answer some practice questions.
Which items are included in the discussion section of an incident report?
Options:
Option 1: This option is incorrect. There should be a separate section of the incident investigation report covering recommendations.
Option 2: This option is incorrect. Information about the extent of damage and repair estimates belongs in the account of the incident section of the report.
Option 3: This is the correct option. The discussion section of an incident investigation report should include an analysis of the causes of the incident. Causation is addressed at three levels: direct, indirect, and root cause.
Option 4: This option is incorrect. Names of witnesses would belong to the background information section of the report.
Correct answer(s):
What are the four key elements of an incident investigation report?
Options:
Option 1: This option is correct. An incident investigation report should include background information, such as what work was going on at the time of the incident and what people and equipment were involved.
Option 2: This option is correct. The incident investigation should describe what happened: the sequence of events, the type of incident, the damage done, and the source of energy or hazardous material involved.
Option 3: This option is correct. The report should include a discussion section that presents an analysis of the direct, indirect, and root causes of the incident.
Option 4: This option is correct. An important component of the report is the recommendations section. Short-term and long-term actions to prevent similar actions in the future should be included.
Option 5: This option is incorrect. An abstract of the report may be a good idea, but it is not one of the key elements of an incident investigation report.
Correct answer(s):
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