Incident Management
Completing an Incident Investigation (Supervisor/Monitor Guide)
How to document investigation findings, including contributing factors, root causes (Standard, 5 Why, ICAM), and recommendations.
For incidents requiring formal investigation (status 'Open'), the Supervisor or Confidential Monitor conducts and documents the findings. The depth of this section may vary based on the incident's assessed potential risk.
Documenting the Investigation
Core Investigation Details
- Investigation Start Date & Team: Record when the investigation began and who was involved.
- Sequence of Events: (Required) Clearly outline the chronological events.
- Witness Statements: Summarize or attach statements.
Identifying Factors
- Immediate Contributing Factors: Detail any substandard conditions (e.g., poor housekeeping) or acts/practices (e.g., failure to follow procedures) that contributed.
- Root Causes:
- Root Cause Investigation Type: Select the methodology:
- Standard: For less complex issues, identify job/system factors, personal factors, type of contact, and contact with.
- 5 Why: If selected, complete the "5 Why" analysis section to drill down to the fundamental cause.
- ICAM: For significant incidents, choose this to link to or initiate a new, detailed ICAM investigation. See the "Using the ICAM Form" guide for more.
- Root Cause Details: (Required) Summarize the primary root cause(s) identified.
- Root Cause Investigation Type: Select the methodology:
Reporting and Recommendations
- Recommendations: Propose corrective and preventive actions.
- Cost: Estimate any associated costs.
Reviewing Linked Records
- Associated Actions & Hazards: Ensure actions are created for recommendations and that associated hazards are reviewed and updated. Refer to "Actions Management" or "Hazard Management" documentation as needed.
Attachments
- Add the formal investigation report and any supporting evidence.
Preparing for Sign-Off
- Authoriser: (Required for this workflow path) Select the person who will review and approve the investigation.
- Comments: Add any notes for the Authoriser.
Submitting for Sign-Off
- Use the 'Submit For Sign Off' (or similar) action to send the completed investigation to the Authoriser. This changes the incident status to 'Pending Sign Off'.
Version: 1
Completing Incident Classification Outcomes Details
Reference guide for the specific information required based on the 'Classification (Outcomes)' selected for an incident.
Using the ICAM Form for Major Incident Investigations
Guide to the ICAM (Incident Cause Analysis Method) form for in-depth root cause analysis of major incidents.