Investigation of Incidents: Reporting The Outcomes

Certificate IV in Occupational Health and SafetyAn incident report provides a condensed formal record of facts and recommendations surrounding an incident, giving each level of management information with which to decide and prioritise remedial action.

The investigator’s memory, like that of a witness, is fragile and will tend to sub-consciously fill in gaps where no evidence exists: it is a peculiarity of the human mind. The investigator does have the advantage of photographs, evidence, exhibits, notes taken at the time and statements to refer to which will refresh their memory, however the best approach is to prepare a written report as soon as possible, preferably before they get involved in another investigation.

Remember the old adage: “The job’s not done until the paperwork is finished.” When preparing a report, the author, in this case the investigator must assume the reader does not have any knowledge about the workplace or the work practices. Indeed they may not have knowledge of safe work practices. Every aspect will need to be spelt out, in a concise format, being careful not to become verbose.

The report, like the investigation, also needs to be a methodical, systematic, unemotional record of the facts and events that led to an incident, description of evidence and exhibits collected, together with an analysis of the causal factors and recommendations for preventative strategies. Remember there must be a beneficial outcome for the resources expended on the investigation.

The depth of the report, the analysis of the causal factors and recommendations will be influenced by the seriousness of the incident, the extent of the injuries received and what type of investigation is being undertaken, by whom and for what purpose. An internal investigation will be looking primarily at developing preventative strategies. Whereas an investigation by a statutory authority will probably be looking at breaches of legislation, and will be less influenced by the seriousness of the injury, but more by the extent of any breach of legislation.

The report should contain sufficient information to enable a decision maker to act on the investigator’s recommendations. Be aware that any modification or change to equipment, work procedures etc., will cost money. Consequently cost benefit factors should be included with recommendations in an internal investigation report. The report should commence with a brief overview of the incident, when, where, what and to whom, followed by a broader outline of the workplace, the work being undertaken at the time of the incident, and the events leading up to the incident. These headings will probably be fairly common to all investigations.

The format of the body of the report will depend on the circumstances of the incident, and will normally address issues such as: the qualifications or training of the injured person, the suitability or condition of any plant or equipment involved in the event, the contributory influence, actions or failures of other persons which may have led to the incident and perhaps other physical factors such as weather, lighting, time of day, length of work shift, working conditions, housekeeping, etc, which also may have had some influence, or which can be discounted as having an influence.

For example: The weather was fine with light breezes and moderate temperature which would have had no influence on this incident. It is better to make a brief statement like this than to have the reader wondering if the weather was an influence, and if the investigator overlooked this matter or just failed to comment on it.

Photographs and sketches should be strategically located throughout the text to enable easy reference and access by the reader. Other relevant documents collected during the investigation and research phases should be included as attachments, clearly labelled and included in a contents page as well as being referenced at the appropriate part in the body of the report.

The report will conclude with comments or discussion of issues that have arisen or need to be addressed, the conclusions reached by the investigator together with appropriate recommendations including preventative strategies from the investigator. Without this step, the whole investigation and report have been a complete waste of time.