HSEP 5.4a2, Rev.

0
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

 Detailed description of incident including the following:

o Location (site or office)

o Type of person (from JSIMS)
o Date and time of occurrence
o Date and time reported
o Response to incident
o Consequences of incident

Summary of Causal Analysis

 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

Conclusions and Recommendations

 Provide a summary of the conclusions and recommendations from the
investigation

Copyright© 2014, Jacobs Engineering Group Inc.

03/19/14
 HSEP 5.4a2, Rev. 0
Incident Investigation Report Template
Introduction

Background

 Description of the project, site or office including scope of work and other
relevant information

Incident Investigation Process

 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.

Facts and Analysis

Incident Description

 Describe the incident in detail and include photographs and other supporting
graphical information as necessary to support the description

Chronology of Events

 Provide a detailed chronology of events (including photos or sketches where

appropriate) based on the facts

 Include the events leading up to the incident, the incident itself, and the events
following the incident until the scene was secured

Response to the Incident

 Describe the immediate response to the incident by all parties involved in the
response process.

 Describe subsequent actions taken by the investigation team based on

information obtained during the investigation (notifications to other projects or
sites regarding interim findings, recommendation of work stoppage of similar
activities, etc.)

Investigative Readiness and Scene Preservation

 Describe the steps and actions taken to secure the scene and the investigation
team assessment of those actions.

Incident Causal Analysis

 Describe the methodology or methodologies used to perform the causal analysis

of the incident (5 Why’s or other method)
Copyright© 2014, Jacobs Engineering Group Inc.
03/19/14
 HSEP 5.4a2, Rev. 0
Incident Investigation Report Template

 Present a summary of the analysis (graphical form is preferred)

 Identify the basic causes, the indirect causes and root causes

Examination of Evidence and Supporting Analysis

 Describe any specific examination of physical evidence (including tools and

equipment) that was performed to support the investigation (e.g., metallurgical
analysis, functional testing of equipment, structural analysis, etc.) and the
outcome of that examination or analysis

 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:

o Fitness for duty

o Fatigue
o Environmental factors

Conclusions and Recommendations

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)

Copyright© 2014, Jacobs Engineering Group Inc.

03/19/14
 HSEP 5.4a2, Rev. 0
Incident Investigation Report Template

Recommendations

 Describe the recommendations or statement of need based on the conclusions

(e.g., the on-the-job training of fire watch personnel should be revised to ensure
that it adequately addresses location-specific emergency procedures)

 When corrective actions are recommended they should be selected using the
hierarchy of risk control measures

o Eliminate the hazard

o Substitute with a safer process, equipment or material
o Incorporate engineering controls (guards, equipment modification, etc.)
o Establish administrative controls (procedure, work instruction, permit,
training, etc.)
o Use personal protective equipment

Attachments (as applicable)

 Sketches
 Photos
 Training records
 Permits/tags
 Plans
 Procedures
 Risk Assessments
 Licenses
 SPA
 Technical Records
 Statements
 Other

Copyright© 2014, Jacobs Engineering Group Inc.

03/19/14