The Incident Report Form
Section IV. Recommendations and Results
Recommendations should address the causes identified during the analysis. If the report identifies only surface causes, corrective actions may address the immediate problem without addressing the underlying system weaknesses that allowed or contributed to it.
Section IV of the sample report separates recommendations into corrective actions and system improvements. Corrective actions address the hazardous conditions and actions associated with the incident. System improvements address underlying weaknesses in programs, plans, policies, processes, procedures, and other elements of the safety management system.
Recommendations should be specific enough for decision-makers to understand what needs to change. The report should also describe the intended result or positive impact of the recommended action. Each recommended corrective action should address an identified cause.
Sample recommendations that address surface causes
- Stop irrigation-pipe installation in the affected area until appropriate controls are established for work near the energized overhead power line.
- Provide affected employees and supervisors with training on the procedures and precautions required before work resumes near the overhead power line.
Sample recommendations that address root causes
- Revise the work-planning process to require identification and control of overhead electrical hazards before work begins.
- Develop or revise safe work procedures for handling irrigation pipe and other long materials near energized overhead power lines.
- Revise the safety training program to include the procedures and precautions employees and supervisors must follow when working near energized overhead power lines.
- Assign responsibility for verifying that required controls are in place before work begins near overhead electrical hazards.
Sample Results
- Recommendation: Revise the work-planning process to require identification and control of overhead electrical hazards before work begins.
- Intended result: Overhead electrical hazards are identified and appropriate controls are established before employees begin work.
Section V. Summary
This section provides a brief summary of the incident, the causes identified, and the recommended corrective actions. When reliable cost information is available, the summary may also compare estimated incident costs with the investment required to implement corrective actions and the expected benefits of those actions.
Cost information can help decision-makers understand the financial impact of the incident and the value of prevention. However, recommendations should be based primarily on how effectively they address identified causes and control hazards.
Section VI. Review and Follow-up Actions
The investigation process does not end when the report is written. Section VI documents the actions taken in response to the findings and helps ensure that corrective actions and system improvements are carried through to completion.
Follow-up responsibilities should be assigned to people who have the authority, knowledge, and resources needed to complete or monitor the assigned action. Responsibilities should be clearly assigned in three areas:
- Implementation — Who will make the change?
- Monitoring — Who will track its status and effectiveness?
- Review — Who has appropriate authority to confirm that the response adequately addresses the findings?
Depending on the corrective action, responsibilities might be assigned to the following employees and managers:
- Supervisors to implement revised work practices or verify that required procedures are followed.
- Safety personnel to coordinate corrective actions, review procedures, provide technical assistance, or monitor completion.
- Maintenance or engineering personnel to repair, modify, replace, or redesign equipment and physical safeguards.
- Training personnel or qualified supervisors to develop or provide required training and evaluate employee understanding or performance.
- Department managers to provide resources, approve operational changes, and ensure assigned corrective actions are completed.
- Senior management to authorize or support corrective actions that require organization-wide changes, significant resources, or changes to the safety management system.
The person assigned to complete a corrective action does not necessarily have to be the person assigned to verify it. A supervisor might implement a new procedure, for example, while a safety professional or manager later verifies that the procedure is being used and is effectively controlling the hazard.
For example, a department manager might be responsible for revising the work-planning process, a safety professional might assist with developing procedures and training, and the affected supervisor might be responsible for implementing the new procedures with employees. A manager or safety professional could then follow up to verify that the changes were implemented and are working as intended.
Follow-up should determine whether the corrective action was completed as intended, whether it effectively addresses the identified cause, and whether it created any new or unintended hazards. If the action is not effective, additional corrective action may be necessary. The incident investigation report should generally be considered ready for closure when corrective actions have been completed and appropriately reviewed.
Section VII. Attachments
Attachments provide supporting information and evidence related to the investigation and its findings. Depending on the incident, attachments may include photographs, sketches, interview notes, records, diagrams, and other relevant documentation.
Attachments should be clearly identified and organized so readers can connect them to the appropriate information and findings in the report.
Depending on the incident, attachments may include:
- Photographs and video records
- Incident-scene sketches and diagrams
- Interview notes or statements
- Equipment inspection and maintenance records
- Training records
- Relevant policies and procedures
- Equipment manuals or manufacturer information
- Applicable permits or work plans
- Other records or evidence supporting the investigation findings
Knowledge Check Choose the best answer for the question.
8-5. When should an incident investigation report generally be considered ready for closure?
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