Incident investigation information resources

This section describes the formal approval and acceptance method for the report and where the final report and any supporting documentation will be maintained. It may state the company document retention policy for incident investigation or refer to another resource to determine how information must be kept. 

Use shared external learnings to determine what others have successfully used. Information sources mentioned in Section 4.5.2 are excellent resources for information, such as incident investigation learnings and successful use of various metrics. 

This typically considers injuries to personnel and damage to plant and equipment. In a few more highly developed systems, information on potential consequences is also collected. Normally the severity of the incident consequences (or in some cases its potential consequences) will determine the resources that are put into its investigation. 

Information derived from data-gathering activities serves as the basis for valid conclusions and recommendations. Without effective data gathering, the incident cannot be defined or analyzed effectively. In some cases, gathering data can consume most of the time and resources spent by the investigation team. Some teams report that it can take up to 70 percent of the investigation effort depending on the nature of the occurrence. 

The source of the data was insurance claims files and records of plant owners, which cannot provide reliable accident causal data because they rarely include causal factors. Nor are accident investigation reports completed by supervisors adequate resources for causal data. When this author provided counsel to clients in the early stages of developing computer-based incident analysis systems, insurance claims reports and supervisors investigation reports were examined as possible sources for causal data. It was a rarity for insurance claims reports to include information from which causal factors could be selected. 

One of the most fundamental challenges that faces investigators when dealing with large quantities of relatively minor incidents is how to identify and assess the risk of what is reported, and so properly focus attention, prioritise action and allocate resources within the organisation. In practice, the primary tool provided for this purpose in most safety information systems is a risk profile matrix, risk table or risk map. These are simplistic tables... 

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