Investigations

An Investigator opens an investigation for an incident or near miss and connects it to the relevant assessment and organization. Record the site and occurrence date while the details are fresh. The severity rank and corrective action description help the reviewer understand what happened and what response is being considered. The assessment connects this account to the period, operating unit and controls under review.

Suppose a near miss occurs at a plant entrance. The Investigator records the site, occurrence date and observed hazard, then checks which assessment covers that operating unit. A control test under the same assessment may reveal an exception, and the finding gives the action owner a specific gap to address. Keep the original event account clear even as the response develops.

• Draft account. The Investigator records site, occurrence and the proposed corrective action before submission.
• Submitted review. The Independent Reviewer sees the source revision and supporting evidence before deciding.
• Recorded outcome. The decision and subsequent status show whether the investigation can be completed.

An investigation may move from Draft to Submitted, Approved, Rejected or Completed. Those states should describe the actual decision reached, rather than a desired finish date. A rejected investigation needs a reason and a corrected account before another review. A decision belongs to the assessment and identifies the examined revision; compare both before using it for this investigation. The reviewer should be able to find the related assessment, action evidence and retest when assessing the submitted version.

Agree who may submit the investigation and who serves as Independent Reviewer. Define the team’s meaning of severity rank and where supporting evidence belongs. Choose a consistent way to identify sites so an incident can be compared with the operating unit on its parent assessment. Confirm what a completed investigation means in the organization’s operating practice.

Take a real near miss through a draft account, finding, action and retest. The Investigator should see the current status; the reviewer should see the same site, occurrence and revision that were submitted. Record a Return or Reject decision with a reason when the evidence is insufficient. After an accepted decision, compare the investigation with the finding’s action evidence and passing retest before marking it complete.

• Investigations awaiting review — Submitted incidents ready for an independent decision.
• Investigation board — Working incident accounts grouped by status.
• Completed investigations — Closed accounts with a recorded decision date.

Use incident review for the decision handoff and action verification for the finding response under the same assessment.