You’ve completed your HAZCHEM incident investigation and you have a better understanding of what happened and why. The next step is to report your findings to the people (usually the business owner or senior management) who have the authority to implement corrective actions and introduce chemical control measures. The purpose of your report is to help those in authority understand the magnitude of the incident, why it happened, what issues of non-compliance still exist, and the actions needed to rectify compliance breaches as well as prevent it from happening again. This blog will help you set out an incident investigation report.
PLEASE NOTE: The examples used in this blog are fictitious and are designed the demonstrate a process rather than offer causal explanations.
Describing the incident
Your report should begin with a clear (and succinct) description of what happened. Most incidents can be described in a couple of paragraphs, and to make it easy to read, break up the text with headings, bullet points, or tables. The incident description should:
- Describe the sequence of events in the order they happened.
- Relay facts without speculation.
- Indicate any areas where the evidence is unclear.
- Use job titles rather than a person’s name.
- Not attribute blame or describe causal factors.
REMEMBER: Your report will have a separate space to explain root causes and recommend corrective actions. Don’t include these in your opening description.
Example of a description (extract only)
On 27 May 2010, WORKER A from the administration department entered the laboratory with a trolley of stationery boxes. When WORKER A opened the door, WORKER B was walking towards the sink carrying two containers of 98.3% concentrated sulphuric acid. WORKER B was hit as the doors swung open and acid spilled from the bottles.
While it is still unclear if the lids to the acid containers were in place, acid splashed onto the arms, face, and eyes of WORKER B as well as onto the floor and surrounding bench tops. WORKER A was not immediately splashed but in the course of helping WORKER B to the emergency shower and eyewash station, acid contacted their hands and arms.
Explaining root causes
Your report should contain a section that details the root causes you’ve identified during your investigation. Each root cause should be linked to a system failure and you should explain how it contributed to the incident. Here is an example.
Carrying highly corrosive chemicals incorrectly. The chemicals were carried by hand instead of with a trolley. A trolley was available in the lab for moving the concentrated sulphuric acid, and a documented procedure was in place requiring staff to use the trolley and never hand-carry the highly concentrated acid.
Opening the door with force. Rather than opening the door smoothly then propping it open while bringing the trolley through, the door was kicked open with force and the trolley rushed through before the door closed.
Example of contributing factors
Ineffective supervision. Supervisors were aware that lab staff were not using the trolley when transferring chemicals and this had become a common practice.
Opaque doors. The doors to the laboratory are opaque and swing in both directions. Workers on either side have no idea if anyone is standing with their range when opening the doors.
Recommending corrective actions
Your investigation report should provide a list of recommended corrective actions; each corrective action should indicate how it will address a hazard or compliance issue. You could set out your corrective actions like this:
|Causal factors||Contribution to the incident||Recommended corrective action|
|Carrying chemicals incorrectly||Chemicals were carried by hand instead of with a trolley||Reissue the work procedure and counsel each lab worker individually.|
|Opening the door with force.||Doors swung open forcefully and struck the lab worker on the other side.||Have laboratory staff collect their own stationery from the administration building.|
Allowing unsafe work practices to become standard work procedure.
1. Review the job description of the lab supervisor.
2. Review the roster and work hours of the supervisor.
|Opaque doors||Workers were unable to tell if someone was standing within striking range of the door.||Install clear panels in the laboratory doors.|
As you can see from our example above, some causal factors may require more than one recommendation for corrective action. Your own investigation report might have a more detailed explanation of the corrective action than in our brief example.
Other information to include
The most effective Investigation Reports are succinct and provide enough information to help the reader understand what happened without getting bogged down in long winded explanations or unnecessary scientific jargon. Some longer items are better placed as appendices at the end of the document. Here are some suggestions:
- Names, roles, and relevant details of members of the investigation team.
- Overview of working methodologies (causation models, process for appointing the team and assigning responsibilities, )
- List of key evidence (photographs, drawings, test results)
- Priority list of compliance issues.
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