Accident Report - from Wrong to Better

It should be clear that learning from unwanted events - from things that did not go as planned or expected - is vital to optimizing the organization and its processes: it may be vital to survival.

Not learning from what went wrong is an opportunity missed. Not learning means that situations remain as they were and the same or similar events may occur, possibly with quite different consequences.

Start of the learning process is to get the accidents, incidents or other type of unwanted events reported and registered. The basis for that is a good accident investigation protocol.

The next step after having the event reported is the accident report, on paper or electronically.

Accident Report: from Unwanted Event to Management System

The various activities which make up an investigation come to focus in the accident report. This could be either in written form or electronic.

The report form is much more than merely a device to inform management. It is the basic element of managerial control over the investigative process. The form directs the investigator's actions. It asks the questions he or she must answer. It guides consideration of cause factors and then leads to remedial actions.

The report must identify the elements involved and the loss. It must accurately describe the elements and conditions as a base point so the merit of later analysis can be weighed and factors bearing on management decisions can be carefully considered. This permits the investigation to have wide application over company activities. Often special sections of a report form can be tailored to equipment and processes used, to enhance the performance of the investigation.

The report should information including:

• factual information:
• • description of what happened
  • the actual results of the event
  • persons involved
  • equipment or material was involved
  • activities preceding and during the event
  • date, time and place of the event
  • emergency actions taken
  • pictures of event situation
  • immediate remedial actions taken
  • etcetera

• risk classification - determination of potential consequences, "what if?"

• cause analysis
• • direct causes
  • basic causes
  • management system factors

• remedial actions - including assignment of responsibilities for follow-up

Management leadership

Essential to a sound accident investigation program is upper management participation. In addition to review of reports for satisfactory quality, management participation involves allocation of resources for remedial actions, and lateral applications of the knowledge gained from the accident investigation. Classification of risk is an important factor in getting management attention and support in the process.

Professional help

The professional enters the reporting process in three ways: 

(i) designs the report forms and keeps them current for the organization

(ii) analyzes the data for trends and implications.

(iii) measures of the quality of reports. In such manner, he can promote thorough investigations and quality reports which enable full control by management.  

Accident report rating

Using the accident report example, the quality of the reporting can be measured by designing a simple rating system as indicated below - sample only.

Once you have the rating system for the reporting set up, you will be able to put a quality score on actual reports made. The scores can be fed back to the originator and be used for (re)training purposes.