Report documents incident investigation

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. 

The initial incident report is very important. This document captures the initiator s firsthand knowledge of what occurred in the moments after the specific event. Example 5-2, Sample Toller Initial Incident Report, is an example of the data that should be documented as soon as possible. Note that it should be modified using the company s management system procedure and incident investigation procedure, which should describe the type of data needed, and level of detail desired. 

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

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. 

In summary, the report is the vehicle for transmitting and documenting the investigation. It is a direct reflection of the quality and professionalism of the incident investigation team. The entire team should review the report before release. 

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 ... 

Einally, the committee noted that complete documentation supporting incident investigations was not always retained with the reports or in a report Hie. For example, a videotape relevant to the December 3, 2000, incident at JACADS could not be located for the committee to view. 

Absolutely, there has to be a documented incident reporting and investigation procedure. But, that s not enough. It s recognized in the model companies that specialized training is necessary to achieve sophistication... 

Incident Investigation PSM must include investigation of aU incidents that resulted in or could have resulted in a catastrophic release of a highly hazardous chemical in the workplace. The standard requires documented incident reports. 

In previous years, the EPA site had a heading for EPA/OSHA Joint Chemical Incident Investigation Reports. A dozen or so were listed under that heading. Now these valuable well-researched documents typically in excess of 50pages are now available via the search engine. It appears that most of the incidents were in the 1995 to 1998 period and can be individually searched with a keyword as the incident location or organization name. 

Make sure that all incidents are promptly reported, thoroughly investigated, and documented, and that safety recognition programs do not discourage reporting of incidents... 

Gather evidence from many sources during an investigation. Get information from witnesses and reports and observation. Get copies of all reports (documents containing normal operating procedures, flow diagrams, etc., maintenance charts, or reports of difficulties or abnormalities). Keep complete and accurate notes. Record pre-incident conditions, the incident sequence, and post-incident conditions. In addition, document the location of employee, witnesses, equipment, energy sources, and hazardous materials. 

Observation requires reporting, documenting, and assessment or investigation in order to produce a response to the undesired behavior. The results must also then be shared and communicated to all levels. In other words, the organization must learn from its mistakes and undesired behaviors prior to the occurrence of an incident. 

It is essential that all incidents are reported promptly, and in detail—even those that have only minor consequences or that are first aid cases or that are near misses. In the United States, incidents that meet the OSHA guidelines for recordability must also be documented and reported. (The topics of Incident Investigation and Root Cause Analysis are discussed in Process Risk and Reliability Management). 

Injury/incident investigation and reporting. This document contains the basic procedures and requirements for recording and reporting occupational illnesses and injuries as well as identifying the cause(s) of the accident or near-miss occurrence. In turn, this information can be used to implement corrective changes to preclude the recurrence of similar incidents. 

Many companies use the form that documents the original discovery of a hazard to track the correction of the hazard. Inspection reports include notations about hazard correction alongside the information about the hazard. Employee reports of hazards and reports of accident/incident investigations also should provide space for notations about hazard correction. 

Employers must develop in-house capability to investigate incidents that occur in their facilities. A team should be assembled by the employer and trained in the techniques of investigation, including how to conduct interviews of witnesses, assemble needed documentation, and write reports. A multidisciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened and why. Team members should be selected on the basis of their training, knowledge, and ability to contribute to a team effort to fully investigate the incident. 

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