Desirable Content of an Incident Investigation Report

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This document offers guidance on how to conduct and develop an Incident Investigation report for incidents involving merchant vessels and their crew. The guidelines are applicable to any type of incident or vessel.

Key Sections

Executive Summary
- Brief, factual overview of what happened, consequences, contributing conditions, and recommendations.
Background Information
- Description of pertinent information that is helpful for the reader to understand the investigation report.
Incident Description
- Chronological narrative of events leading up to, during, and immediately after the incident.
- Includes preamble, immediate and short-term post-incident actions.
- Supported by photos, diagrams, or sketches.
Root Cause Analysis (RCA)
- Use industry-standard methods (e.g., 5 Whys, Fishbone Diagram, Fault Tree Analysis).
- Differentiate between immediate, underlying, and root causes.
- Emphasizes “domino effect” theory of cascading causes.
Incident Analysis
- Identify critical factors that, if eliminated, would have prevented the incident.
- Narrative of actions, omissions, and conditions contributing to severity.
- Review similar events and iterative data collection.
Recommendations
- Strengthen risk prevention and mitigation barriers.
- Address leadership and cultural issues.
- Include interim residual risk measures and monitoring plans.
Evidence
- Supplementary materials in appendices: corrective action proof, timelines, permits, risk assessments, crew experience, diagrams, photos, logs, VDR extracts, test reports, certificates, personnel statements, audits, and maintenance records.

References

Includes IMO guidelines, ISM Code, MAIIF manuals, and ABS guidance on marine incident investigations.

Click here to download the guidance on Desirable Content of an Incident Investigation Report.