WRITING A SUBSTANTIAL INCIDENT REPORT

Author
J.R. Moody

An incident report is one of the most valuable tools an employer can have in their commitment to a safe and healthful workplace. After managing the aftermath of an incident, it’s important to move forward in ways that ensure a similar incident doesn’t occur again in the future – to learn from mistakes, so to speak. A strong incident report will help you achieve this goal by detailing the events surrounding the incident, identifying a root cause, and leading to an effective course of corrective action.

The incident reporting process consists of four steps:

Step 1: Control the Scene

Before you can do anything, you need to make sure the scene of the incident is under control. If the scene remains hazardous, such as in the case of fire or chemical spill, those dangers need to be neutralized and workers evacuated as necessary. If any workers were injured during the incident, they must receive the appropriate first aid, plus medical attention or transportation to a medical facility if the injuries are severe. A supervisor should be notified as soon as possible if for some reason one wasn’t present during the incident.

After focusing on controlling imminent hazards and injured workers, it’s time to lock down the scene. Only authorized personnel should be allowed in the area. Do not move any items unless absolutely necessary for safety, as you will want to properly document the scene with photographs and drawings during the next step.

Step 2: Conduct an Investigation

Since the end goal of an incident report is a corrective action plan, you’ll want to know as much as possible about what led up to the incident. Without a clear idea of how the incident occurred, you won’t be able to determine what measures to implement in order to prevent it from happening again.  To obtain this information, an investigation is necessary. Scrutinize the incident scene carefully, taking pictures and sketching a layout that accurately depicts the area. Having this information documented may be beneficial beyond the report itself, should you find yourself subject to OSHA investigation.

There is a limit to how much information you can gather by evaluating the scene of the incident; the rest of what you need to know will come from those involved. Conduct interviews with workers present for the incident as soon as possible, while their memories are still fresh. Interviews should be performed with tact and care, especially if the incident was severe, as workers involved may be under a lot of emotional stress. Furthermore, it’s possible a worker will be on edge out of fear that the interview will lead to disciplinary action. Speak calmly, professionally, and reassure the worker that your only goal is to learn about what happened.

Between investigating the scene and interviewing workers, the information you want includes:

  • Date, time, and location of the incident
  • The names, positions, and immediate supervisors of those involved, and witnesses
  • Events surrounding the incident (before, during, and after)
  • Exactly what those involved were doing when the incident occurred
  • Details of property damage
  • Specifics regarding any injuries, including what part of the body was injured, what type of injury, and the severity of the injury, as well as what treatments were administered
  • Environmental conditions, such as weather (if outdoors), slippery surfaces, noise levels, etc.
  • Tasks performed, equipment and materials involved, and personal protective equipment used

Take care to document this information in your report as thoroughly as necessary to ensure that anyone reading it would be able to develop a clear mental picture of the incident based on what you’ve written. Generally speaking, because this is essentially a preventative tool, the more information provided the better.

Step 3: Analyze Information and Determine Root Causes

This is where you’ll find out exactly what your corrective action will address. If you’re only looking at the big picture, you’ll see a variety of contributing factors which led to the incident. These are important in terms of making the proper adjustments going forward, but what you really want is to know what caused the incident at the core. This is known as the “root cause.”

Let’s imagine a new employee was operating a powered industrial truck (PIT) when he lost control and crashed into a stack of pallets. Injuries were minimal, but there was a good amount of property damage and everyone involved was shaken. After a thorough investigation, it was determined that the PIT had faulty brakes. Now, to determine the root causes of the incident, you’ll want to ask a series of questions that look beyond the obvious. The obvious states that bad brakes led to a loss of control, but why were the brakes faulty? Is there a preventative maintenance schedule (and if one was followed, why wasn’t the PIT marked as out of service?)? The employee was new – had he received adequate training and certification prior to operating the PIT? Why wasn’t the PIT inspected before use?

The answers to these questions will provide you with your root causes, which lead to the final step:

Step 4: Develop a Corrective Course of Action

With your incident report fully fleshed out, the last step is to use the information you’ve acquired to determine and document precisely how you’ll prevent a similar incident from reoccurring. Revisiting the previous example, this would include implementing a written preventative maintenance schedule and holding maintenance personnel accountable for it. If the new employee had not received the training necessary to safely operate a PIT, then you’ll want to examine how training is administered and how supervisors can test for skill. Once you’ve implemented corrective actions, be sure to reexamine your report at a later date in the near future to ensure these actions were sufficient.

 

 

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