The Investigation Report

General

An serious injury/fatality accident investigation report may consist of a factual section and a management evaluation section. The sections can be inserted into a three-ring binder with tabs identifying each.

The complete investigation report should be presented in draft form to the safety manager for review.

Factual data, such as maps, pictures, and weather data may be included as appendixes to the factual section if they are needed for clarity or understanding of the sequence of events. Other evidence, such as witness statements, autopsy photos, portions of policy, emergency logs, and equipment that are not appropriate or are too bulky to include in the factual section should be placed in the case file.

IMPORTANT: To the maximum extent possible, do not use names or other personally identifying information in the factual or management evaluation sections. Use of names or other personal information usually requires redaction to comply with Privacy Act regulations. To maintain the factual section of the investigation report as an accident prevention tool, use the positions of the individuals involved in the accident, such as dozer operator, crew boss 1, witness 3, instead of their names. This approach allows those interested to understand the roles of the participants and keeps the agency from being accused of covering up relevant data.

1. The factual section includes: the cover, title sheet, table of contents, executive summary, narrative, findings, causal and contributing factors, and appropriate appendixes. Examples of applicable appendixes are:
   • Maps
   • Fire behavior synopsis
   • Weather summary

   The purpose of the factual section for use as an accident prevention tool for management, employees, and other interested agencies. This information about the facts and the findings of the accident will help prevent similar types of accidents.

2. The management evaluation section includes an executive summary and recommendations to prevent or reduce the risk of similar accidents.

Factual Section

• Cover.
• Title Sheet. The name and location of the accident or incident, the date of the accident or incident, and the list of investigation team members and their respective departments.
• Table of Contents. Use three-ring binders to set up the document, with dividers for each section of the document. Include page numbers. When a section includes supporting documents (such as maps, photos, or technical reports), refer to the tabs and page numbers of the exhibits and figures.
• Executive Summary. The summary briefly explains how the accident occurred. It normally should not exceed one page.
• Narrative. The narrative portion explains why the accident happened. It should provide a detailed chronology of the facts, before, during, and after the accident.
  • Do not identify involved personnel by name in the narrative. Identify involved personnel by their position.
    • Who had an active role in the accident?
    • Who were injured in the accident?
    • Whose actions or inactions initiated or sustained the accident sequence?
• Maps, photographs, illustrations, graphics, figures, and exhibits can be included or referenced in the factual section but need to be properly identified (for example: figure 1, figure 2).
• Findings. Conclusions of the accident investigation team based on the chronological facts, weight of evidence, professional knowledge, and good judgment. They are grouped in the factual section in the following categories: human, material, and environmental. Each finding should, where possible, be supported by two or more facts from the investigation.
• Causal Factors. Any behavior or omission or deficiency that started or sustained the accident occurrence.
• Contributing Factors. Any behavior or omission or deficiency that contributed to, but did not directly cause or sustain the accident or incidence occurrence.

Appendixes

Appendixes can be used as reference information in the factual section.

Management Evaluation Section

• Executive Summary. The summary briefly explains how the accident occurred. It normally should not exceed one page.
• Recommendations. Suggested measures that management may take to prevent similar accidents. They must be reasonable, feasible, and relate to the causal or contributing factors of the accident. All recommendations must allow for a definite solution to the problem. Every causal factor should have recommendations for future prevention or mitigation, although exceptions may occur.
• Number recommendations consecutively (for example: Recommendation 01, Recommendation 02).

Case File

The accident investigation case file has two components: the accident investigation report (factual section and management evaluation section), and the supporting documentation and equipment that are not in the investigation report. Cassette tapes, photos not used or unfit for distribution, witness statements, and documents that may be too large, should not be included in the investigation report. They should be kept in the case file and only referenced in the accident investigation report to support the team’s findings.

Any equipment that the investigator thinks should be kept, such as a hardhat that failed, becomes part of the case file.

Source: USDA