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Incident Investigation Report Template
Use this incident investigation report template (or similar template) to document
incident investigations for Serious Incidents in accordance with HSEP 5.4.
Note: Depending on the complexity of the incident and other factors, not all elements of this
template may apply.
Report Data
Title
Number
Date
Investigation Team Members (including team lead)
Executive Summary
Incident Description
Direct Cause(s) – describe the direct causes associated with unsafe acts and/or
conditions
Indirect Cause(s) – describe the indirect causes associated with people and/or
execution factors
Root Cause(s) – describe the root (or basic) causes related to management
and/or programmatic factors
Background
Description of the project, site or office including scope of work and other
relevant information
Describe the investigation process including the date and time the investigation
started and concluded (with issuance of report), the methodology used and any
unique or specific terminology that was used in the report.
Incident Description
Describe the incident in detail and include photographs and other supporting
graphical information as necessary to support the description
Chronology of Events
Include the events leading up to the incident, the incident itself, and the events
following the incident until the scene was secured
Describe the immediate response to the incident by all parties involved in the
response process.
Describe the steps and actions taken to secure the scene and the investigation
team assessment of those actions.
Identify the basic causes, the indirect causes and root causes
Describe the examination of the work processes and the outcome of that
examination. Work processes include but may not be limited to:
o Risk assessment
o Safe Plan of Action (SPA) or equivalent
o Pre-start activities (morning meeting, tool box meeting or equivalent)
o Work permit process
o Training
o Supervision
Describe the examination of other factors and the outcome of that examination
such as:
Summary of Causes
Provide a summary of the root cause(s) and the contributing direct and indirect
causes
Include the events leading up to the incident, the incident itself, and the events
following the incident until the scene was secured
Conclusions
Describe the conclusions drawn based on the investigation and the causal
analysis (e.g. the investigation concluded the on-the-job training of fire watch
personnel was inadequate as it did not address location specific emergency
procedures)
Recommendations
When corrective actions are recommended they should be selected using the
hierarchy of risk control measures