015 Incident Report Template

The TOP-SET® Accident / Incident Report Template
About this document

This document has been created by The Kelvin Consultants using their TOP-SET ®
methodology. Its aim is to allow you to record all the different contributing factors and
elements of an incident or accident for future reference and reporting.
About TOP-SET®
The TOP-SET® Accident / Incident Investigation System has been in use since it was
originally developed at the request of a major company in 1988. Since then it has been
used increasingly in the UK and throughout the world and is now used in more than 30
countries. During this time it has been constantly reviewed, refined and developed often
in consultation with our customers who know what works.
TOP-SET® is a straightforward, widely used and validated system of investigation which
enables an investigator, whether experienced or not, to get to the heart of an incident. It
is a total process taking you from data gathering, through Root Cause Analysis to
profiling.
How can I use TOP-SET® in my company or organisation?
You can either attend one of our training courses which will teach you how to apply
TOP-SET® or commission The Kelvin Consultants to create a specialised course
especially for your company or organisation.
For more information call us on 44 (0) 1475 560 007
How to use this document
The template has been broken down into a series of sections. We have provided hints
and advice for each section and they are contained within a <<series of brackets>>
Note to users of this Template: You can easily remove all the hints & advice text:
(1) Select Edit > Replace…
(2) Check "Use Wildcards"
(3) Copy this string: \<\<*\>\>
(4) Paste it into the "Find" box
(5) Leave the "Replace with" box empty
(6) Click on "Replace All"
Tel: +44 (0) 1475 560 007 Fax: +44 (0) 1475 569 011 Email: info@kelvintopset.com Web: www.kelvintopset.com
This will delete all text enclosed between double pairs of angle brackets - so don't use
them in your own text or that will be deleted too
[REPORT] INTO
<<ADD DETAILS OF INCIDENT HERE>>
BY
<<NAME, POSITION ETC>>
<<DATE>>
TABLE OF CONTENTS
<<You can insert a table of contents here by using the Insert>Index and Tables > Table of
Contents command in Word, based on the Outline Levels already used in this template,
or customised as you prefer>>
Summary Section
Summary of the Incident

<<In the following section, describe in the simplest language possible the what, when,
where and who of the incident you are investigating. Remember -- your readers may
not be familiar with technical terms or abbreviations. If in doubt, get someone outside
the industry to read your report through.>>
What happened
<<Here is where we describe, in the plainest terms, and making no assumptions, what
happened. For example, "The Tacoma Narrows Bridge collapsed" / "The Titanic sank" /
"Two trains collided head-on" / "Pipes fell from sling during crane lift" etc>>
When it happened
<<The date of the incident>>
Where it happened
<<The location of the incident>>
Who was involved

<<Name the principal parties to the incident - that is, people directly involved as, for
example, drivers, operators, injured parties etc.>>
The consequences
<<Give the actual consequences of the incident -- for example, "The falling load struck
the banksman, breaking his arm. He had to go to hospital and is expected to be off work
for 4 weeks. The load also struck two barrels of degreasing fluid, rupturing one and
releasing its contents into the work area.">>
The possible consequences

<<Because it's important to investigate "near hits" -- in order to avoid actual hits in
future -- it's also important to give possible consequences here. For example: "The
banksman narrowly escaped being killed. There was also the risk of a more serious
chemical spill.">>
The investigating team

<<Here is where you describe:
Who you are
Who asked you to investigate the incident
Your qualifications for investigating, if necessary
The names and occupations of the members of your investigating team, where
appropriate.>>
Summary of Conclusions
<<In this section you will summarise, using the top-level TOP-SET® headings, the
conclusions your Investigation reached. Again, use the plainest possible language and
short sentences. Your aim is for clarity and precision.>>
Reasons for and causes of the incident
Immediate Causes
<<Remember how to identify immediate causes: if one of them hadn't occurred, this
particular incident wouldn't have happened either. We have given some samples below,
under the relevant headings.>>
Technology
<<The sling broke during the lift, allowing the pipes to fall>>
Organisational
<<The lift was unsupervised>>
People & Human Factors

<<The banksman was standing directly beneath the load>>
Environmental Factors
<<Hazardous chemicals were stored near the lifting site.
The crane driver could not see the banksman.
Strong winds, gusting to 35kt, made the load swing unpredictably.>>
Root Causes
<<As TOP-SET® trained investigators, you will need no reminding what root causes are!
Again, give them under the relevant top-level headings.>>
Technology
<<Maintenance of the lifting equipment was erratic and slipshod.>>
Organisational
<<Refresher training for staff was inadequate.
Maintenance schedules were not closely supervised.
Risk assessments were not regularly carried out.
Financial pressures led to risk-taking by staff.>>

<<The crane driver was uncertain of his authority. The banksman was "tired" after a
series of sleepless nights because of sickness in his family.>>
Environmental Factors
<<Housekeeping was poor. Site design, which had been recently changed, meant
inadequate sightlines between driver and banksman>>
Summary of Recommendations
<<This is possibly the most important section of the report. The Summary section is the
part that everyone will read, and the Recommendations are the part of that section
which will make a difference in the future. So it's worth going the extra nine yards to
make sure your recommendations here are:
o Clear
o Achievable
o Likely to be implemented.
Again, simplicity and clarity of language are vital.>>
Recommendations: Technology
<<An immediate and detailed check to be made on all lifting equipment.>>
<<Radios to be provided for communication between drivers and banksmen>>
Recommendations: Organisational
<<A programme of refresher training to be drawn up and implemented as soon as
possible and in any case within six weeks from the date of this report.
Maintenance schedules to be reviewed and maintenance staff to be fully re-briefed.
Schedules to be regularly monitored to ensure they are being kept to.
A full and formal risk assessment of the site and its tasks to be carried out, preferably by
external consultants working together with the HSE.
Re-allocation of resources to be looked at.
Rules regarding supervision of hazardous work to be tightened.>>
Recommendations: People & Human Factors

<<A balance to be made between the "can-do" culture currently in place and the need for
staff to monitor their own fitness for work.>>
<<A program of training for on-site risk assessment by supervisors to be put in place.>>
Recommendations: Environmental Factors

<<Housekeeping to be generally improved
Separate and secure storage areas for hazardous materials to be set up.>>
Main Body of the Report
<<This is the "full text" of the report. Not everyone, by any means, will read the whole
thing; but it is more than just a "cover-your-backside" exercise. It's your document of
record. And, more to the point, it is a valuable legacy for people investigating
subsequent incidents. Some of it may duplicate or, more probably, expand on points
raised in the summary. Remember that the Summary and Main Body should be able to
be read independently of each other. Don't assume anyone will read both parts. If that
means repeating yourself, so be it.>>
Aims and Objectives
The Aims of this Investigation

<<Set out what you intended to do when you started. E.g. "The Investigation was
intended to get to the root causes of the incident on 26 February 2003">>
The Objectives of this Investigation

<<Set out what you intended to accomplish by carrying out the investigation. E.g. "The
Investigators' objective was to make recommendations addressing those root causes
which, when put into effect, would ensure that this class of incident could not happen
again.">>
Description of the Incident

<<Describe the incident you are investigating. What happened? When? Where? What
were the consequences? Who was hurt? What was damaged? (Remember reputation!)
Who could have been hurt -- or worse? What could have been damaged or destroyed?>>
Methods of Investigation
The Investigation Leader

<<Describe yourself. Who are you? Who asked you to investigate? What are your
qualifications etc?>>
The Investigation Team

<<In similar terms, describe the members of your team.>>
Site visits made

<<Note here each and every site visit you made, including
o When you made it
o Who went
o Any relevant conditions (bad weather, limited access etc)
o What you were looking for
o How you looked for it
o What you found>>
Graphical material etc.

<<Here is where you should attach any photographs, diagrams, sketches etc. that are
relevant.>>
Documentation consulted
<<List - with details where needed -- any documentation you looked at including, for
example:
o Maintenance/procurement records
o Ops manuals
o Standard Operating Procedures
o Permits to Work
o Risk Assessments
o Personnel records (including training)
o Log books
o Time sheets
and so forth>>
Persons interviewed
<<List all the people you interviewed, together with a summary of the interview notes.
No need to include a complete transcript, nor material which turned out to be irrelevant
("Mr Stubbs then said, strike a light, he was parched, any chance of a cuppa?")>>
Tests & Simulations etc.

<<Note any tests, reconstructions, simulations (computer or otherwise) etc. you may
have done. Give proper sources where necessary, so that people can locate them later.
>>
Findings of the Investigation
Timeline: Sequence of Events Leading to the Incident

<<A simple table of events is best here, with the appropriate timeline down the left hand
column and the events down the right. E.g.>>
<<Tuesday <<INCIDENT. Sling breaks, Pipes fall, striking banksman and
15.28>> rupturing nearby degreasing-fluid drums>>
<<15.26>> <<Wind begins to gust up to 35kt (crane driver's estimate). Lift
continues>>
<<15.24>> <<Second lift begins>>
<<15.20>> <<Second lift rigged (banksman and labourer)>>
<<15.17>> <<First lift to test rig area completed successfully. Pennant returned to
pipe storage racks.>>
Organisational Factors: Control & Responsibility

<<List here all the relevant factors your investigation identified, under
the headings which follow. If there were no significant findings for a
given factor, you might like to say so, for the sake of completeness. E.g.
"Contamination: Contamination was investigated but was not a
factor.">>
Management/Supervision
Culture and Morale
Methods and Procedures
Safety Controls/Systems
Legal Considerations & Consequences
Contractors and Others
Resources and Finance
Planning
Knowledge and Decisions
Other
People and Human Factors
Injury and Potential Injury
Activities and Tasks
Attitudes and Behaviour
Skills and Training
Health and Fitness
Communications
Personal Protection
Other
Similar Events
<<This is an important section, if only because it's often the one organisations are least
on the ball about. The discovery that an incident may have been preceded by one,
several, or maybe even scores of similar events often comes as a shock -- whether those
events are inside the company, the industry as a whole, or even in the "outside world".>>
Within the enterprise itself

<<Note here any similar events within the company.>>
Within the sector

<<Note here any similar events within the industrial or commercial sector the company
is operating in>>
External to enterprise & sector

<<Note here any external similar events. For example, in 1938, when the Tacoma
Narrows suspension bridge -- which collapsed in crosswinds in November 1940 -- was
built, the aerodynamic problems which caused its (literal) downfall were already well-
known. But not to civil engineers. Aircraft designers, though, knew them all too well.
Cross-pollenation between industries would have revealed a great deal of "similar
events" knowledge which, had it been known and heeded, might have prevented the
incident from happening.>>
Environmental Factors & Effects
Weather
Natural Effects
Pollution
Contamination
Housekeeping
Location
Error-Inducing Conditions
Other
Technology Factors: Equipment & Processes
Equipment and Maintenance
Operating & Processes
Operating Instructions
Materials
Power/Energy
Design & Layout
Other
Causes of the Incident

<<In this section, in much the same way as in the Summary section above, list both
Immediate and Root Causes under their relevant TOP-SET® headings. This practice not
only makes the causes clearer to the reader, but gives your Report force by tying your
recommendations directly to the root causes. You will probably wish to gather your
causes (and indeed your recommendations) under at least the second-level TOP-SET ®
headings (e.g. Organisation > Safety Controls/Systems), if not even more precisely under
the headings in the Expanded TOP-SET® Indicators (see your manual for further
details.)>>
Immediate Causes
Organisation
Environment
Technology
Root Causes
Organisation
Environment
Technology
Recommendations of the Investigation

<<Again, lay out your recommendations in accordance with the TOP-SET ® indicators, to
tie everything together and give your overall report extra coherence and authority.>>
Organisation
Environment
Technology
Appendix
Root Cause Analysis chart

<<It is worth appending your Root Cause Analysis chart as the final piece of evidence
which can convince even the most sceptical of readers of the power of your arguments.
A neatly-drawn Root Cause Analysis can be easily "read" by someone who has no prior
knowledge of the incident at all. For a relatively simple RCA chart, you might (if you
are using an up-to-date version of Microsoft Word) use the Organization Chart feature
in the program, which does the job admirably. (See the Word Help menu for details)>>

015 Incident Report Template

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015 Incident Report Template

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The TOP-SET® Accident / Incident Report Template

About this document

Summary of the Incident

Who was involved

The possible consequences

The investigating team

Reasons for and causes of the incident

People & Human Factors

People & Human Factors

Recommendations: People & Human Factors

Recommendations: Environmental Factors

Aims and Objectives

The Aims of this Investigation

The Objectives of this Investigation

Description of the Incident

The Investigation Leader

The Investigation Team

Site visits made

Graphical material etc.

Tests & Simulations etc.

Timeline: Sequence of Events Leading to the Incident

Organisational Factors: Control & Responsibility

Culture and Morale

Methods and Procedures

Legal Considerations & Consequences

Contractors and Others

Resources and Finance

Knowledge and Decisions

People and Human Factors

Injury and Potential Injury

Activities and Tasks

Attitudes and Behaviour

Skills and Training

Health and Fitness

Within the enterprise itself

Within the sector

External to enterprise & sector

Environmental Factors & Effects

Equipment and Maintenance

Operating & Processes

Design & Layout

Causes of the Incident

People and Human Factors

People and Human Factors

Recommendations of the Investigation

People & Human Factors

Root Cause Analysis chart

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