Executive Summary

Brief, factual summary of what happened, the consequences (or lack of), a preview of the conditions or actions that contributed to the incident (correspondent with Incident Analysis) and a summary of the recommendations.

  • Incident Summary

  • Causes

  • Key Findings

  • Corrective Actions

  • Proposed Recommendations related to key findings to prevent re-occurrence

  • Fleet Lessons Learnt circular also addressing actual and potential severity and the impact of the incident in a high profile area

Background Information

Description of pertinent information that is helpful for the reader to understand the investigation report

  • Location

  • Activity at the time

  • Applicable policies and procedures

  • Personnel involved

  • Equipment associated with the incident

Incident Description

Narrative detailing pertinent facts about the incident that describe what happened and not why.

The intent is to enable the reader to have a good understanding of the relevant events leading up to the incident, the incident and its immediate consequences. Typically, this section will be organised chronologically and can be supported with photographs, diagrams or sketches.

  • Preamble describing the scene just prior to the incident

  • Narrative description of what happened and consequences

  • Post incident immediate actions

  • Post incident short term actions

Incident Analysis

Incident Analysis should include identification of critical factors and a narrative on the findings from the Root Cause Analysis.

  • Critical Factors which if eliminated would have prevented the incident

  • Narrative describing actions, omissions, conditions and events that led or contributed to the incident and/or increased its severity

  • Review of similar events on vessel or in the fleet.

Recommendations

Recommendations should be designed to strengthen risk (prevention and mitigation) barriers, or address organisational leadership and cultural findings.

  • Recommendations based on all findings from the Incident Analysis

  • Residual risks in the interim before recommendations are fully implemented

  • Measures / Plans in place to monitor effectiveness of Recommendations

Evidence

To include more detailed supplementary information (as applicable) necessary for the reader to understand what happened, the investigation findings and learnings. Material (which can be collated in an appendix) should be pertinent to the report and referenced in the main body of the report and may include (but not be limited to) the following:

  • Evidence of Corrective Actions

  • Chronology

  • Timeline

  • Permits

  • Risk Assessments & Hazard Identification

  • Crew Experience Matrix

  • Procedure extracts

  • Diagrams/plans

  • Photographs

  • Charts

  • Plans

  • Checklists

  • Logbook extracts

  • Data logger / VDR extracts

  • Test and Analysis reports

  • Class reports

  • Certificates

  • Flag notifications & dispensations

  • Third Party Service reports

  • Planned & Unplanned Maintenance reports and records

  • Personnel statements and factual statements

  • Interview extracts

  • Audit reports

  • Medical reports

Root Cause Analysis

The RCA should be carried out using an industry standard RCA method.

  • RCA

  • Immediate Causes

  • System Causes

  • Systemic Causes

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