Laurie Wilson - RISSB - Derailments reports

Major Occurrence reports

Presenter Laurie Wilson

Date May 2015

Location Sydney

Purpose

• No matter how thorough an investigation has been, the

report delivered at the end of it can make all the difference to

the effective implementation of safety actions.

• The purpose of the investigation report is to provide an

accurate and objective record of the occurrence being

investigated.

Factual

A report is a factual text which:

• states what an event was and how / why it occurred

• identifies causes and contributors and

• provides recommendations to address those causes

and contributors to improve safety

Outcome

Reports provide rail organisations with the basis for

developing corrective actions to prevent or

minimise risk of a recurrence of accidents and incidents.

Draft reports

Preliminary draft and review reports should be provided to

recipients in confidence for the purposes of preparing

comment or representations, or to commence remedial action.

What to include

An investigation report must be clear, concise and give

complete and accurate statements • who authorised the investigation and terms of reference

• the investigation process (methodology) – how it was done

• information about where and when the accident/incident happened

• facts about what happened

• findings and observations based on the facts

• a risk assessment of the activity being undertaken at the time of the incident

• review of the current risk assessments and risk control measures relevant to the

incident

What to include

• analysis of the findings, events and conditions contributing

to the occurrence

• conclusions about why the accident/incident happened

• safety actions/recommendations

• organisational error chart or events and conditions chart to

assist management in understanding the factors

contributing to the occurrence.

Report levelsAS 4292.7 and the code of practice specify four levels of investigation.

The required level of detail in the report for each is as follows.

• Level 1/2 Report - A fully detailed report produced as specified in

AS 4292.7.

• Level 3 Report - A brief report including analysis where

appropriate, produced in accordance with the applicable principles

in AS 4292.7.

• Level 4 (notification only) - Formal reporting other than the initial

occurrence notification will not normally be required.

Organisations may only require the recorded occurrence detail to

be included in summaries for submission to the responsible

authority.

Detailed Report contents and Structure

Cover/Title page

Table of Contents

Executive summary

Terms of reference

Investigation Methodology

Factual details

Sequence of Events

Findings and Analysis

Conclusions

Safety actions already taken

Safety Actions/

Recommendations

Organisation Error Chart or

Event and Conditions Chart

Sequence of events

This is required to outline what happened in a chronological

order. Includes what was intended, who was doing it and what

happened.

For the sequence of events you may use bullet points or free

flowing English or even a time line in a table format.

Findings & analysis

This is a key area of the report where you present the evidence

and discuss the findings.

A logical flow is essential to presenting a good case.

Findings & analysis

Discussion of the what, when, where, why and how the

occurrence happened.

The findings identify system safeguards:

• what systems were/were not in place?

• what systems were inadequate or ineffective?

• what systems were/were not complied with.?

Causal statements

Someone should be able to pick a report up five (5) years later

and follow the logical flow and reasoning.

Every contributing factor and cause must be supported by

discussion of findings and logical reasoning in the body of the

report.

Check Check to see that you have given a clear picture of the

occurrence and covered:

• the sequence of events

• what actually happened (e.g. two wagons derailed on a

section of track in a siding under repair)

• how it came to happen (e.g. the local track supervisor did not

identify that the track could not support the train before

allowing it to proceed into the siding), and

• why it happened (e.g. inadequate standards and training for

running trains on track that is undergoing repair and

disturbing works).

Conclusions

The reader needs to understand the link of what happened, how

and why.

Do not just state what the investigation determined was the

cause of the occurrence.

Conclusions

Conclusions must not apportion blame to individuals.

• Each conclusion should reflect a single key finding.

• Do not introduce any new information in this section that has

not been previously mentioned. If this is done it can reveal

the investigation is incomplete.

• Conclusions are not meant to further discuss issues.

Conclusions

Conclusions should link and be cross referenced to the

relevant finding/analysis section where they were discussed in

detail.

They also cross reference to the appropriate safety actions or

recommendations.

Example Organisational Error Chart ILCI Loss Causation Model

Absent/Failed Defences Immediate/Direct Cause/s

Local/Workplace Conditions Basic /Underlying causes

Organisational factors Root Causes (Lack of Control)

Safety Actions already taken

Investigators may recommend to the responsible manager any

preventative safety action that needs to be taken promptly to

prevent or minimise risk of similar occurrences prior to

completion of the report.

safety recommendations are written• to prevent or minimise risk of recurrence

• address absent/failed defences and workplace/organisational

factors.

• with a sequential number and cross reference and link directly with

a conclusion

• by not including any issues that are not listed in the Terms of

Reference unless there was additional safety issues identified or

scope expanded during the investigation.

• in a manner not to apportion blame on the individual or suggest

disciplinary actions.

• with to the position title (not name) of the appropriate

manager/supervisor who has to action it.

Safety actions

SHOULD NOT They Should

be prescriptive

be a detailed directive

include names but positions

titles

include issues that did not

contribute to the occurrence

not include opinion, wish lists

or I wants

be for disciplinary action

be a direct link to the occurrence

address and link to the causes and

contributing factors

address organisational and

systemic deficiencies

suggest action to prevent or

minimise risk of recurrence

be based on hierarchy of controls

be cross referenced to the causes

and contributing factors

be S.M.A.R.T

safety recommendations

Should focus on what needs to be changed

rather than how to do it.

Check the report

It is unrealistic to expect the first draft to be the finished

product. Skilled writers draft, edit, rewrite and check

Organisational review

• Organisations should review all reports

• Allocate actions to a position

• Identify lessons learned and circulate

• Identify improvements in the reporting process or document.

What constitutes a good report

• Clear – Make sure the purpose and intent is clear to the reader.

• Complete – check that the document is logically structured.

• Concise –Keep it to the point.

• Courteous - strive for a positive and neutral tone.

• Correct – Edit and proofread.

RISSB

Questions