The Incident Report Form
Section III. Findings and Justifications
This section documents the surface and root causes identified during the analysis. Each finding should include a justification that explains the evidence supporting the conclusion.
A finding is stronger when the report identifies the evidence supporting it. For example, a finding about inadequate training might be supported by training records, the training materials used, employee interviews, and established work procedures.
The finding states the conclusion. The justification identifies the evidence supporting that conclusion.
- Surface cause findings describe the hazardous conditions and actions that contributed to the incident.
- Root cause findings describe the underlying safety management system weaknesses that allowed or contributed to those conditions and actions.
An investigation should not stop after identifying a hazardous condition or employee action. For example, stating that an employee worked too close to an energized power line identifies an important surface cause, but it does not explain why the work was performed that way. The analysis should continue by examining factors such as work procedures, training, supervision, planning, and other elements of the safety management system.
Do not ignore the action. Do not stop at the action.
Findings should be factual, specific, and supported by evidence. Avoid vague conclusions such as “employee carelessness,” “failure to use common sense,” or “poor safety culture.” Instead, describe the condition, action, or system weakness that the evidence supports.
Write findings as complete descriptive statements rather than short or cryptic phrases. The following examples illustrate how surface and root causes might be documented.
- Surface Cause — Hazardous Condition: A high-voltage power line was located directly over the area where employees were laying irrigation pipe.
- Surface Cause — Action: Employee #1 raised an irrigation pipe vertically within unsafe proximity to the energized high-voltage power line.
- Root Cause — Work Procedure: The established work procedure did not provide adequate requirements for handling irrigation pipe near energized overhead power lines.
- Root Cause — Training: The training provided to Employees #1 and #2 did not adequately address the procedures and precautions required when working near energized overhead power lines.
- Root Cause — Work Planning: The work-planning process did not adequately identify and control the overhead electrical hazard before irrigation-pipe installation began.
Knowledge Check Choose the best answer for the question.
8-4. What should support each causal finding in an incident investigation report?
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