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
Root Cause Analysis (RCA)
The RCA should be carried out using one of a number of industry standard RCA methods.
5 whys, Pareto Chart, Fishbone Diagram, Scatter Diagram, Affinity Diagram, Fault Tree Analysis, Comprehensive Chart of Root Causes, Comprehensive List of Causes, M-SCAT, MaRCAT are just some to mention.
Root causes typically differ from underlying (less obvious) causes which in turn differ from immediate causes. There is a “domino effect” theory, causes act like chains of events, one results in another and like in falling dominoes does not necessarily result in an incident – when the distance between dominoes is sufficient and/or the angle of the previous one does not result in its contact to the following one.
Example: Immediate cause is an unsafe act or condition. Underlying Causes is a the reason for the unsafe act or condition. Root Causes is a failure in management control and/or the safety management system.
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.
Analysis is a repetitive process and does refer to other tasks of the investigation. It is common that during analysis further data is needed and should be collected. Analysis starts with the start of investigation and finishes once the report is competed – after all amendments and updates.
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
Further publicly available reading about requirements.
ISM Code Reg. 9
MSC-MEPC.7/Circ.7 Guidance on Near-Miss Reporting
Resolution A.1075(28) Guidelines to Assist Investigators
IMO Res. MSC.255(84) The Code of the International Standards and Recommended Practices for a Safety Investigation into a Marine Casualty or Marine Incident (CIC)