Incident investigation reporting

The final incident investigation report written by the assigned incident investigation team (which may include members from the client) can be written in a less structured way depending on the extent of the incident. A detailed discussion of how and why to conduct incident investigations can be found in the AIChE publication. Guidelines for Investigating Process Safety Incidents, Second Edition. 

In the case of incident investigation, a major milestone is completed when the final incident investigation report is submitted. The incident report documents the investigation team s findings, conclusions, and recommendations. This chapter describes practical considerations for writing formal incident reports, a discussion of the attributes of quality reports, and the issue of commimicating the report findings to affected persons, both internally and externally. 

They ensure documentation exists explaining why a recommendation was rejected or modified after its original approval in an incident investigation report. 

At this stage of review, before writing the full incident investigation report, only the essential recommendations may have been developed. However, line management are invariably more interested in these key recommendations, and tbe other less critical recommendations may not be reviewed with management until the report has been drafted. 

After presentation of the incident investigation report findings and recommendations to management, follow-up activities can fall into three distinct groups ... 

Were there any legal issues from this latest investigation that were related to incident investigation reports or documentation that need to be resolved before the next major incident investigation ... 

The following case study describes the investigation work process for a hypothetical occurrence using a logic tree based multiple root-cause systems approach. An example incident investigation report follows the work process description. The example is intended for instructive purposes only descriptions of process equipment and conditions are not intended to reflect actual operating conditions. 

Incident investigation reports shall be retained for five years. [1]... 

Ensure that the incident investigation report is reviewed with affected personnel whose jobs tasks are relevant to the incident findings. 

Naturally, while awaiting additional investigation or laboratory test results, it may be necessary for preliminary reports, status reports, and draft reports. However, the final incident investigation report must satisfy the requirements of the OSHA Process Safety Management standard. An OSHA PSM report shall, at a minimum, include ... 

Tips on the Style and Content of Incident Investigation Reports... 

Incident investigation reports are retained for at least the legal minimum of five years. 

Incident Investigations Reported by Others Can Provide Valuable Insights... 

N. N. Thermal decomposition incident. Investigation Report 2001-03-I-GA NTIS number PB2002-107365, U.S. Chemical Safety and Hazard Investigation Board, National Technical Information Service, 5285 Port Royal Road, Springfield, VA 22161, June 2002. 

General discussion and guidance to do with professional writing in general is provided in Chapter 16. Additional issues to do with the writing of an Incident Investigation report are discussed here. 

Effective incident investigation, reporting, and follow-up are necessary to achieve improvement in health, safety, and environmental performance. They provide the opportunity to learn from reported incidents and to use the information to take corrective action and prevent recurrence. 

The source of the data—insurance claims files and records of plant owners — cannot provide reliable accident causal data. From personal experience, 1 can say that insurance claims reports rarely include causal data. And my studies of incident investigation reports completed by supervisors require the conclusion that they are not a reliable source for valid causal data. 

In three exercises, I collected a total of 905 incident investigation reports completed by supervisors for an analysis of the quality of incident investigation. With emphasis, I state that the study I made would not meet the modeling and methods requirements of scientific inquiry. Nevertheless, some interesting observations were made. 

Incident investigation reports received had a variety of titles, although some were identical. They come under these names, which in themselves have significance ... 

Of the 15 variations of incident investigation reports received, six promote an overly simplistic and inappropriate approach to causal factor determination. They reflect this instmction, although somewhat ancient, given in a publication of the American National Standards Institute, the Method of Recording Basic Facts Relating to the Nature and Occurrence of Work Injuries—Z16.2. 

Generally, few supervisors did a good job of ergonomics problem identification. Although there has been an emphasis on ergonomics as a significant aspect of the practice of safety, that emphasis was not seen in the content of the incident investigation reports reviewed. 

It is a too common practice that persoimel with safety in their titles place their signatures, indicating acceptance and approval, on incident investigation reports that are far from adequate, particularly concerning causal factor determination. 

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