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1 st Reporting

Conducting A Root Cause Analysis: Incident To Final Report

Posted 3.02.21 by: Bond Seidel

Incidents can happen in the blink of an eye. And reporting these incidents helps to drive progressive change to a safer workplace. But what happens when the cause of an incident is unclear? A root cause analysis suddenly isn’t just appropriate. It’s crucial. And knowing how to conduct a root cause analysis is as important as knowing how to report the incident in the first place.

A Root Cause Analysis is conducted by following 6 steps, beginning with the incident report and ending with a comprehensive root cause analysis. Understanding each stage of the root cause analysis is vital for successful preventive action plans creation and implementation.

Root cause analysis, also known as RCA, is the investigation process following an incident. The incident may or may not have caused harm to a person or property. Incidents may not have occurred at all, but instead, someone reported a dangerous situation. Either way, a root cause analysis ought to find completion following any form of incident.

This article will discuss the steps necessary to conduct a root cause analysis to a successful end. Tracing the incident’s steps and following the reporting and root cause analysis process to the end, we will find many useful tips and tricks to help facilitate your company’s reporting processes. Let’s jump right into why we want to do a root cause analysis in the first place to get us going.

Table of Contents

Why Conduct A Root Cause Analysis If There Is An Incident Report?

It may seem duplicative, even counter-productive, to produce a root cause analysis report following a previously reported incident. And in a sense, it may be slightly repetitive, but this is no reason not to complete a root cause analysis.

The sole purpose of a root cause analysis is to determine all the factors that contributed to an incident’s occurrence. It is a proactive management tool used to serve the process of corrective action.

An incident report documents an incident. However, those who complete incident reports are often more involved in reactive management of an incident than proactive management of the event. It is merely the nature of the beast.

To perform a root cause analysis, step out of reactive and progress towards proactive incident solution management.

So, why conduct a root cause analysis? Couldn’t we take a different approach to the incident report? Sure, you could do it, but why complicate a situation where reactive management is vital in controlling further incident damage or injury? Often incidents require a certain amount of reactive action merely to contain a hazard, which is often best left to its own devices.

Maintaining a separate procedure for root cause analysis allows for a more focused approach to proactive incident management. It also evades the corruption of a reactive issue’s causal factors that may, in the heat of the moment, obscure the real root cause as to why an incident occurred in the first place.

6 Steps To Completing A Root Cause Analysis

Analyzing industry-specific responses to incidents, we find that a complete root cause analysis procedure is completed best with a predefined set of steps.  Wikipedia decomposes the RCA into four steps:

• Identify and describe the event.
• Establish a timeline from ordinary events to the incident event.
• Distinguish between the root and causal factors.
• Establish a causal graph connecting the root cause and the event/problem.

We believe that taking things to a more generalized, less industry-specific approach, and yet in more depth and detail, is appropriate. Here’s our take on completing a root cause analysis in most industries; see below.

• The Incident Report Analysis

Determining Leading Events

Analyzing leading conditions, documenting further witness information, analyzing completed data collection.

• Determining Corrective Action 

The Incident And Report Analysis

Beginning with identifying an incident, we analyze the incident to determine its characteristics. The incident often finds presentation via an incident report, but there are many possible sources of information for the incident. For example, the RCA may generate following a customer complaint, risk management referral, or even a complaint presented by HR. No matter the source generated by the RCA, you have to start identifying the problem or incident. 

As many RCAs are generated following incident reports, let’s go a layer deeper into these reports. An incident report should include the following:

• Administrative details
• Incident information
• Witness accounts and observations
• Actions and recommendations

The information provided ought to include as much information as possible; however, if you perform a root cause analysis, the incident will have already been recorded in the report. Analyze the information provided and look for holes in the information. Try to find any omissions, which can sometimes be the case.

For more information on what to include in incident reports, please read our article: 12 Things To Include In An Incident Report (With 5 Tips) .

As you analyze the incident report, a story should start to form in your mind about how it occurred. Aside from acts of nature, most incidents have precursor events. It is the classic cause and effect scenario. And it would help if you determined said causes.

When an incident occurs, we can determine any events that could have avoided the incident itself if removed. 

Although events that lead up to incidents are apparent contributing factors, sometimes conditions are the prerequisites for incidents. At this stage in the root cause analysis, you should examine the conditions that surrounded the incident. Careful analysis of available data might reveal clues to establish the root cause or causes further. The information may also help us sort out the root causes from the other causal factors.

In certain incident types, witness information may require you to conduct a follow-up investigation. When analyzing the incident report data, depending on the nature of the incident, information might even be omitted simply by the assumptions of those involved at the time. Hindsight is 20/20, as they say.

Further witness information may include more than mere statements of those who were present to perceive the incident. The information may come from other forms of witnesses, such as the electronic sort. Incidents are often recorded using video surveillance equipment. You can use this to review incidents, and if there are any available other sources of information, you should collect and review them.

The fifth stage of the root cause analysis is analyzing the completed sets of data. It would be best if you had determined your leading events, the conditions surrounding and leading up to the incident, as well as any witness information. 

This stage of the root cause analysis requires looking at all of the data you have collected and reviewed. Determine the actual essential factors and events that led up to causing the incident. Separate the essential factors from those that are coincidental or only partially responsible. 

The simple way to accomplish this stage is to ask yourself if you removed that factor, would the incident still have occurred? Would it have been better or worse with that element removed from the equation? If the factor removed means the incident would not have happened, it is an essential contributing factor.

Once all contributing factors are organized, determining the root cause or causes of the incident should come naturally. And this drives us to the inevitable conclusion: how could the incident have been avoided?

Determining Corrective Action – The Final Report

Take a look at the root cause or causes you’ve determined during the course of your analysis. How could these factors have been manipulated to avoid an incident?

Most incidents are preventable. Whether you’re in security, manufacturing, medical care, or any other field, most of the time, we can avoid or prevent hazards from becoming damaging or threatening situations.

Analyze how preventing the incident could have occurred and document any possible and plausible solutions. For best results, document all ideas and eliminate them based on safety and feasibility. Using a methodology to brainstorm possible corrective actions, sometimes we can create a solution that exceeds what standard actions will achieve.

Your final root cause analysis report needs to be concise, comprehensive, and provide solutions. Preventable actions and strategies are always more effective than reactive actions. And you might be able to save someone from injury or worse.

Measures To Follow Through After The Root Cause Analysis

At this point, you’ve completed your RCA if you have followed the steps. But have you followed through on the recommendations? Has anyone completed corrective and preventive actions? The RCA becomes entirely pointless if nothing is done about the incident after all.

During the course of the RCA process, you may be asking yourself what the best method to try to determine the root causes is. Sure, it’s easy to say you need to figure something out, but how should you go about it? Is brainstorming the best option? If not, what is it? Let’s find out.

Root Cause Analysis Methodologies

If root cause analysis were a topic of study, it would be the study of cause and effect, with a major in investigative reporting. But many companies and organizations use a visual charting process as an effective means of communicating the root cause analysis. It is one of several methodologies used in the root cause analysis process. Let’s take a quick look at a few of the most efficient root cause analysis methods.

• Why 5 Analysis

The concept behind the ‘Why 5 Analysis’ is to ask the question Why, five times. For example, one might ask why did this car crash. The answer might be because a left tire blew up. Then ask why that happened, answer and repeat. The concept is to ask the question multiple times to keep diving deeper towards the problem’s root.

Although this method is brilliant in its simplicity, it also happens to be its curse. Many have argued that this method simplifies situations that you should not simplify. The method may inadvertently miss individual branches of thought by misdirection.

During the “Why 5 Method”, if the second “why” results in an answer that starts to lead away from the actual root cause, the domino effect of such a consequence could potentially skew results.

Due to the potential for misleading discrepancies, the “Why 5” method is best used in parallel, multiple times for a single incident. One may also determine that branching in our question chain is not only possible but often quite or even more probable than the assertion that a singular cause is at fault.

• Pareto Analysis

The idea behind the Pareto analysis is the Pareto rule. That is to say that eighty percent of the effects come from twenty percent of the causes. Another way of looking at the Pareto analysis method is to equate the methodology to a looking glass.

A looking glass, or magnifying glass to use a more common name, will take a small area of view and enhance it by presenting the small view on a larger scale. The concept of the 80/20 rule is similar.

The Pareto analysis breaks data into percentages of observations and then is represented graphically. Concurrently, Pareto analysis represented graphically is likely best left to massive data collection types of root cause analysis. This form of analysis uses a statistical-based methodology to conclude. Therefore, it may only be relevant for specific RCA applications. 

• Change Analysis

Change analysis methodology for root cause determination finds credibility in situations involving evolving events or conditions. For example, analyzing the change in roadway conditions over time may allow for determining a root cause when it pertains to a single-vehicle car accident. Or perhaps a facility records notes of equipment conditions over time, and the change of these conditions is analyzed. The idea is that the conditions or events that evolved are analyzed using this method of determining the root cause of an incident.

• Brainstorming

Our most basic and one of our most potent methods for root cause analysis is brainstorming. Because of its power, this method is the one method described in the six steps of conducting an RCA, as mentioned earlier.

The brainstorming method allows freedom of thought to attempt to determine the possible root causes of an incident. Using rough brainstorming followed by a sort of elimination period is one of humanity’s best abilities. It uses the best of our creativity and real-world experience. The downside is that brainstorming can sometimes end up being mono-directional, depending on the person’s mindset or persons involved in the brainstorming process.

Brainstorming Tip: When using the brainstorming method to determine the root cause of an incident, use a minimum of three people to help with brainstorming. This method works best when there are multiple perspectives to help come up with ideas. It also helps prevent mono-directionality.

Conclusions On Conducting Incident Report Based Root Cause Analysis

From the information you’ve read thus far, you must realize that the root cause analysis, as simple or complex a process as you make it out to be, has three primary goals.

• To discover the primary root cause or causes of a problem or incident.
• Next, t o fully comprehend the nature of the incident and how it can be fixed or prevented.
• To apply resolutions as a proactive management tool to prevent the repeat of the incident.

If these three goals find themselves met, then the root cause analysis may be considered a completed process.

Using an incident report as the basis for a root cause analysis is inherently wise from a safety process standpoint. Although, depending on the industry, it may find itself discarded. Take the medical industry, for example. Many hospitals are inundated daily with hundreds, even thousands of incident reports.

The truth is that as industry leaders, we each need to have a process that involves sorting incidents by the level of priority and thus obtaining a resolution to the flood of incidents. If the most severe face triage to a root cause analysis, there may be the hope of achieving a successful reporting system after all.

In most industries, the hope is that there are nowhere near the number of incident reports filed as there are in the healthcare industry. Most businesses shy away from adding further paperwork to their plates, and for a good reason. But, there is a solution to the paperwork dilemma regarding incident reporting and root cause analysis.

Using a digital solution like that offered by 1ST Incident Reporting is the solution to the seemingly never-ending paperwork. With digitally based incident reports, not only can you set up instant notifications, you can access reports previously completed with lightning speed. What better way to do a root cause analysis than have digital access to the incident report?

• Featured Photo by cottonbro from Pexels .
• https://en.wikipedia.org/wiki/Root_cause_analysis
• https://en.wikipedia.org/wiki/Five_whys
• https://www.mindtools.com/pages/article/newTED_01.htm
• https://www.tableau.com/learn/articles/root-cause-analysis
• https://www.cms.gov/medicare/provider-enrollment-and-certification/qapi/downloads/guidanceforrca.pdf

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Toolkit > Critical Incident Management > Learn from Critical Incident Case Studies

Learn from critical incident case studies

Case studies are useful learning tools to help practitioners and institutions respond better to critical incidents, which are events that may overwhelm the ability of an institution to respond. No matter how robust an emergency management plan is, it cannot outline every potential incident and response. Therefore, scenario-based, or problem-based, training has been shown to be the best way to improve non-specific problem solving skills, to enable practitioners to plan flexibly and manage a wide variety of incidents.

minute read

1. Introduction

This module contains six real critical incidents involving international students at New Zealand institutions. We recommend reading the case study, and taking time to think about and respond to the questions for reflection. This can be a useful exercise for your team to do together, to consider ways that your institution would manage a similar scenario. 

Then read on to learn some actions that we suggest you may need to think about in responding to critical incidents of this nature. Note that these are only suggestions and they do not constitute an exhaustive list of all of the actions you might need to undertake, depending on the particular circumstances of any individual incident.

Please note that some of this content might be disturbing for readers unaccustomed to dealing with critical incidents. Thanks to the individuals and institutions who provided case studies anonymously.

2. A road accident

Case study: A road accident 

A group of four international students and one domestic student, who have been studying for a year at your institution, have become friends and decide to venture on a campervan holiday.

The students are travelling on State Highway 1 from Hamilton to Taupo when their campervan hits an oncoming vehicle. 

The students are all taken to Taupo Hospital. One Chinese student and the New Zealand student have minor injuries and are recovering in Taupo Hospital. The Korean and Swedish students have significant injuries and are airlifted to Hamilton hospital. Both are in critical condition. The fifth student, a Chinese national, has major burns and is transferred to the Middlemore Hospital burns unit in Auckland.

Questions for reflection

• What immediate actions should you take to manage this incident?
• Who needs to be involved in responding?
• What resources do you need to immediately support staff in managing this incident?
• Once the incident has been resolved, what longer-term actions might you take as an institution to prevent or ameliorate future similar incidents?

Suggested immediate actions (24-48h)

‍ Establish a response team

When a complex critical incident like this occurs, one of the first things your institution should do is to establish (or activate) a response team to provide the necessary support for the people immediately affected by the incident. The team will also activate your critical incident response plan . Key staff involved in the pastoral care of learners should be part of this team. 

You will also need to decide on roles for the team members. Some possible roles include:

• Leadership/coordination (making key decisions, leading the response)
• Field liaison, support and logistics (travel plans, coordination with insurance, etc)
• Incoming communications (managing calls and enquiries, communicating with doctors and students involved)
• Internal communications (managing messaging to students and staff)

Staff wellbeing

• Family liaison
• Media communications 
• Business continuity (how will your institution carry on with BAU as staff are occupied with managing the incident?)
• Scribe (to record all events in writing as they unfold)

Depending on the size of your institution, each person may need to take on multiple roles. Organise a tasks timetable for the next few days. Plan ongoing feedback and regular meetings, so that the coordinating team is continually in touch and working together.

‍ Working with students’ families

Your family liaison should carefully consider how and when you make contact with the students’ families. As a general rule, communicate as early and frequently as possible, while ensuring you have accurate and sufficient information for them to make any decisions. You may also need to think about facilitating their travel to New Zealand (e.g., arranging visas).

Communicating with other staff and students

The person on your team responsible for internal communications will need to make arrangements for contacting and informing other staff and students about the incident. What guidelines could you provide to staff about the information they give students? A written bulletin to staff may be helpful if the matter is complex. Also consider who may be most at risk and need additional support; for example, friends, supervisors or others who have experienced a similar trauma may be particularly vulnerable.

You may want to arrange a time and place for an initial group/individual debriefing session using counsellors. In this session, participants can be given an opportunity to share the impact of the event, discuss various cultural interpretations of the event, and work through painful emotions. 

Working with the police and emergency services

In a critical incident such as this, the police, hospitals and/or emergency services may have protocols that need to be followed. You should make contact with the appropriate authorities as early as possible, to understand their role and what they will require from you. Clarify things like who will contact the students’ families and how media enquiries should be managed.

Working with the media

Once you have identified your media spokesperson, make a plan for managing media enquiries. It is critical that you anticipate and respond to the media effectively in the event of a major incident like this. If the story does make it into the news, your organization needs to be ready to be a primary and definitive source of information if required, noting that police and/or emergency services may have protocols that need to be followed. If you are not the one telling the story, a story will nevertheless still be told and it may be one that is less accurate and less sympathetic to your organisation. 

You will also need to consider social media. If your organisation is established on a number of social media platforms, it could streamline communications to use a social media aggregator to quickly collect incoming and outgoing messages. Choose one platform such as your website, where you will be posting updates and responding to questions (it is no longer adequate to just transmit, you need to be prepared to interact), and push these messages out to other platforms. 

Supporting your staff

A complex crisis such as this will require a great deal of time and energy from your staff, and it will likely be emotionally taxing, particularly for those who know the students involved. How will your institution support their wellbeing, for example, by ensuring staff take adequate breaks and access support services such as counsellors ? 

Your institution ideally has already made contingency plans for such an incident that includes additional resources that can be brought in to support staff. For example, you may have staff in other parts of the institution who are trained to support critical incidents, or external contractors or agencies you can call upon.

Suggested long-term actions

Once a critical incident is over, one of the most important things that your institution can do is to debrief and learn from the incident to prevent a recurrence and/or help you manage any future incidents effectively. The response team should discuss what went well and what could have been done better. How might you adapt and fine-tune your critical incident response plan with any learnings?

You will also need to consider how you will provide ongoing support for staff and students. For the students and families involved, this could include long-term medical treatment, insurance matters and travel planning. Staff involved in the response may need some time off to recover, and potentially counselling or other support.

You should also consider what other actions your institution might take to prevent incidents like this in the future. For example, in this particular situation, you might consider whether your motor vehicle policy for students was sufficient.

Resources for further information

• ‍ WHO road safety report and ASIRT ‍
• ISANA NZ Critical Incident Kit

3. A student death

Case study: A student death

You receive a call at 8am to inform you that an international student died at a hall of residence last night after what is believed to be an asthma attack.

Police say there are no suspicious circumstances. The student, from Malaysia, had moved into the halls two days earlier. 

The student was found unconscious in his room by other students at about 7pm last night. An ambulance was called and attempts were made to revive him, both by staff trained in first aid and subsequently by paramedics, without success.

• Who will need to be involved?

The fatality of a student is obviously an extremely traumatic event for everyone involved. Your institution’s priority will need to be how to best support the student’s family and friends, other students, and staff. Communications will be critical to ensure everyone involved has adequate and accurate information.

‍ Communicating with the family

Before contacting the student’s family, ensure that you have accurate and up-to-date information about what happened. This may involve talking with the hospital, friends of the student, people present when the deceased was found, and police. This needs to be done quickly so that the family can be notified as early as possible. 

Discuss with the police and other external agencies who will contact the student’s family, and ensure you understand your institution’s role and responsibilities in communicating with the family. Carefully consider who at your institution makes contact with the learner’s family in the case of a serious accident or death. This should be someone senior at your institution to show the significance of the event to your institution.  This may sometimes be done by police.  It is important to ensure clear understanding with external agencies as to roles and responsibilities.

Once the family is informed, it can also be helpful to have an ongoing designated family liaison, who may be someone on your pastoral care team, to maintain consistency and to build the relationship. They can assist the family with travel arrangements, if needed, and ensure their wishes for the burial and services are respected.

The family liaison will serve as the conduit for information going both ways, as well as an advocate for the family within the institution. They will periodically check in with the family to ask if they are getting what they need. In the event of a fatality, this person may need to maintain contact with the family for a protracted period. They may contact the family every few days at first, then once a week, then every other week, and so on, perhaps for years to come.

Cultural considerations

Your institution should ensure that any cultural or religious requirements associated with the death have been respected. What appropriate organisations might offer advice and support? In this case, the Islamic Centre on campus and the local mosque and Muslim community might be helpful. 

Contact consulate

Your response team will need to contact the relevant embassy, high commission or consulate to inform them of the incident and provide them with details about the student. Discuss with the consulate their role in things like contacting the student’s family, arranging a service, arranging travel for the family to New Zealand, temporary accommodation for relatives, and repatriation of the body.

Staff and student wellbeing

As with any critical incident, your institution must plan to support staff and students. Consider those involved in the event (e.g., the students who found the deceased) and those who had a relationship with the deceased (e.g., supervisors, other hall residents, friends). Ensure counselling staff are on standby to support those affected by the incident .

Keep careful records

Be sure to document events in a detailed, written log throughout the response period. This is a requirement of the Code of Pastoral Care and can be especially important in cases where there may be a coronial enquiry, media interest, or police involvement. 

Thanks to Vanessa James and John Pickering for providing this case study.

There will be many things that need to be managed if an international student dies. After the funeral or memorial service, consider the following:

• Does a tapu lifting ceremony need to be conducted?
• Who will obtain a copy of the death certificate and related documents?
• Do you need to assist with repatriation and/or a family visit?
• Should you offer the family a fee reimbursement?
• Arrange condolence letters for the learner’s family.
• Arrange thank you letters for key people involved in managing the incident.
• Who will manage the student’s possessions?
• Does an insurance claim need to be filed or managed?
• Ensure all of the student’s information is removed from your website and databases to prevent inappropriate communications (e.g., marketing, library fines) going out to the family in the future.

As for any critical incident, ensure the response team conducts a thorough debrief afterwards to evaluate and improve your plans, policies, and procedures.

• ‍ ISANA NZ Critical Incident Kit ‍
• NZQA Code resources (critical incident response plan)

4. A suicide attempt

Case study: A suicide attempt  

A 17-year-old student from Singapore has been one of your college’s most promising students.

Her progress over the last eighteen months since she arrived has greatly pleased her teachers and family. 

During the school holidays, she spent time with a university friend at their flat, with her homestay parents’ knowledge and permission, although her parents had not been informed of this arrangement. 

You have just been contacted by the local hospital’s A&E to say that the student is in a critical condition and is fighting for her life. She is semi-conscious after being found in her friend’s flat having taken an overdose. Your business card was found in the student’s wallet. 

Her friend has yet to be located and is not answering her phone. 

The hospital supervisor tells you the police suspect a suicide attempt. Tomorrow is the first day of the new term when students return after a two-week break.

‍ Communications

In this case, quickly forming and initiating a communications team and plan will be a crucial part of your institution’s response. Decide who on your response team will communicate with the hospital, and who will continue to try to contact her friend. How else might you contact the friend for more information? Can you enlist the help of police or other support services?

You will also need to carefully consider how the student’s family will be kept informed. Designate someone as a family liaison who will keep them regularly updated. This person may also need to facilitate their travel to New Zealand. 

You should be cognisant that cultural perceptions of suicide may be very different in the student’s home country (see below), and an awareness of this cultural context will be helpful in managing communications with the family.

Student and staff wellbeing

Consider who else may be affected by this incident and need support. Contact her teachers and close friends when you think it is appropriate to do so and be sure you have counsellors and other support services available to them. You’ll need to decide if/when you make others at your institution aware (e.g., if you think they may find out through other sources), and if you do, you may need to ramp up counselling support for other students who are triggered by the events.

Culture influences many aspects of mental illness and suicide, including what symptoms people show, how they cope, how willing they are to seek treatment, and what family and community support networks they have. 

Psychiatric treatment can be seen as a sign of weakness in many cultures, where students may be more likely to talk to their family or friends about their thoughts and feelings than to seek professional help. In some cultures, people are more likely to seek treatment for physical issues than emotional issues. It’s important for people who work with international students to know that students may experience their psychological distress as physical symptoms (known as somatisation).

There are many ways that the institution could learn from this case study to improve student safety in the future. For example, did the institution require parental permission for students under 18 to travel during the school holidays? If not, how should this policy be crafted to best protect students? If there was a policy in place, why was it not followed in this case, and how can you ensure it is followed in the future?

You could also consider what educational resources you can provide for students about mental illness and suicide. Isolation, loneliness, language barriers, adjusting to a new culture, and being away from support networks may put international students at particular risk of suffering from mental health conditions. How could you better support students with their mental health? Do students know where to go for help if they are having suicidal feelings or other mental health concerns ? 

You may also want to consider how you can reduce the barriers that may make international students reluctant to seek help for mental health issues such as:

• cultural values
• language barriers
• privacy and confidentiality
• poor understanding of the health system

Your institution might also consider providing training for staff and students to be able to recognise the warning sides for suicide and what to do if they’re worried about someone. In this case, the student’s family and teachers seemed unaware that she was struggling with suicidal thoughts. Further resources might help members of your community be more aware of signs and symptoms.

• Understand mental health and wellbeing principles and tools  
• https://www.sieba.nz/mental-health-and-wellbeing/  
•   MoH Preventing Suicide
• MSD guidelines for supporting young people with stress, anxiety and/or depression

5. Hallucinations

Case study: Hallucinations 

A student at your institution has been having hallucinations for a couple of months.

Her flatmates are very concerned about her wellbeing. They contacted their education agency, who then flagged the issue with your team. You meet with the student, and her symptoms are very concerning. She can’t say a full sentence as she gets distracted constantly by a voice that she can hear. She is very pale and thin, as she has not been sleeping or eating well for more than two months because of the hallucinations. She experiences several meltdowns during the meeting because of the distressing things that the voice is saying. 

You accompany her to a GP, who diagnoses the student with mild expression and prescribes some medications. The student is planning to return to her home country, China, in just three days, and the GP confirms that it is safe for the student to fly back to China on her own. However, the student later contacts you and asks to see a psychiatrist, as she wants to get some help and get well first before flying home.

Hallucinations and delusions are two cardinal symptoms of a serious mental health condition, and so as soon as the student contacts you, you should arrange for the student to receive medical attention. If you need urgent mental health support, you can ring your local mental health crisis team . If you’re worried about the student’s immediate physical safety, you should ring 111 or take her to the closest hospital emergency department.  

Some of the things that need to be considered in assessing the student’s safety include:

• What sense(s) are the hallucinations affecting? Hallucinations can affect all five senses. Auditory hallucinations are the most common and may indicate a more serious underlying condition than tactile and visual hallucinations.
• In the case of an auditory hallucination, is the voice commanding and is the person responding to it (e.g., talking back)? Both things might indicate a more serious safety concern.
• Does the person have “insight” into their condition? In other words, do they feel they have a problem? If they don’t have insight, you might be more worried about their safety.
• Is the person under the influence of drugs or alcohol? 
• How long has the person been having hallucinations? In this case, the student has been experiencing them for an extended period, which would make you more concerned.

Accompany the student to her medical appointment to ensure appropriate pastoral case and language support. If the student is assessed and considered to be a risk to herself or others, she will be admitted to a secure mental health unit under the Mental Health Act.

As soon as possible, designate a team member to make contact with the student’s family in China. Be sure to ask the student’s permission to talk to her parents about her mental health issues. If a medical practitioner deems her to be in imminent risk, then you are obliged to contact the family, even if the student doesn't want them to be contacted. You should maintain daily contact with the family throughout the incident to ensure they are kept informed. 

Also with the student’s permission, you may be able to request the support of a hospital translator to speak with the student’s family directly, so that they understand the situation first-hand and can ensure continuity of care when the student arrives home.

Communicating with medical staff

You should ensure that the medical staff involved with her case understand that the student does not have family in New Zealand and is estranged from her friends. Be sure to provide the medical team with a single point of contact and inform them that your institution is obligated under the Code of Practice to support at-risk students. You can ask to be kept informed regularly to get updates on the student’s condition, and to know when the student is discharged so that you can support her after she leaves the hospital. 

Be sure to keep everyone on the response team updated regularly, and to give the team the necessary support and resources to care for their own wellbeing. 

Some longer-term actions that your institution might consider after the incident include:   

• Do you have adequate mental health resources at your institution? In this case, the institution decided to employ a mental health nurse, who can conduct mental health assessments and make triage plans. 
• How can you create strong relationships with medical staff to ensure the best care of your students? You may wish to create a list of medical specialists that you can consult with about particular health issues should the need arise.
• How can you support and protect staff during a protracted critical incident like this? Your staff will need back-up to be able to support the student over a long period, while maintaining business as usual. (The institution involved in this real example said they also changed several policies after this incident to better protect staff's safety. They now order a taxi to pick-up or drop-off students, instead of staff providing student transport, and when possible, they have two staff accompany students who report mental health problems to their medical appointments.)
• Mental Health Foundation - Supporting Others
• SIEBA mental health resources
• Ministry of Health mental health services

6. Sexual assault

Case study description

It has come to your attention from a concerned friend of a young female Japanese student that last Sunday, while out for a walk by the river, the student was accosted and sexually assaulted.

The circumstances and information are vague, and it seems from the information provided, that although the student is very upset by the incident, she is more concerned that if her family and school find out, she might be required to return to Japan.  

You gather from the informing student that apart from the student’s clothing being damaged and some grazing and bruising, the student appears outwardly okay. The student told her homestay host that she slipped.

The friend also tells you that she is concerned for her own and other friends' wellbeing and safety. It is obvious to you that this ripple of concern is beginning to grow as more students seem to be gaining some awareness of the incident. 

At this point the incident has not been reported directly to you or any other person in authority. The student who has alerted you to the incident feels something needs to be done but does not want to betray her friend by reporting the incident.

Ensure students’ safety

In this situation, your immediate concern should be ensuring the safety of the student who was assaulted, as well as the safety and wellbeing of her friends (especially those with knowledge of the situation), and finally, ensuring everyone’s protection from future predatory behaviours by the perpetrator.  

Although the informer has asked for confidentiality, your duty of care is to protect the students from harmful behaviour. You have an obligation to speak with the student who was assaulted and to provide her with whatever resources she needs to feel safe and to manage the trauma she has been through. You should encourage her to see a doctor if she is willing, and offer counselling and other mental health support services. You should also ask if she wants to share any details about what happened so that you can better understand the event in more detail.

‍ Consider privacy

A core issue in managing this incident is balancing the privacy rights of the student who was assaulted with your concerns for her (and others’) wellbeing and safety. Under the Privacy Act , institutions and individuals can report concerns if they believe it is necessary to prevent or lessen a serious threat to an individual’s safety or wellbeing, or for law enforcement purposes. 

Although this is not a black and white issue, in this case, you probably have enough concern to warrant sharing the information you have with both the institution’s leadership and the police. Note that it is always up to the student whether and how much information they want to share with the authorities and whether or not they want to pursue a criminal investigation. You can only share what you know, and encourage the student to share what she knows to protect herself and others.

If the student is under 18, you may be obligated/allowed to share the information with the student’s family and homestay family. Speak with the privacy officer at your institution about what you can and cannot share, with whom, and make sure the student understands your reporting requirements. At the least, you will want to ask her homestay family to stay alert to the student’s mental health condition, and to inform you if they see any worrying signs.

Staff and student support

You will also need to offer support to the informant and other students who have heard about the situation and are concerned for their safety. Again, while respecting the privacy of the student who was assaulted, you can ensure other students have counselling and other mental health support services should they need them. 

You may also want to consider additional security and ways for students and others to report any suspicious activity. The police may have suggestions for actions that your institutions could take. 

As for all critical incidents, ensure you document all communication, and have your response team meet regularly to share information and stay up-to-date. Consider how your institution can support the wellbeing of staff on the response team, ensuring they take regular breaks, have adequate back-up and support, and access to counselling if desired .

Once this situation has been resolved, your institution should review the information provided to students about sexual assault during orientation and afterwards. Do students understand what sexual assault is and what to do if they are assaulted? Do they understand how to navigate the New Zealand health system to get support, and do they understand their legal rights and options? You should also revisit your health and safety plans and policies to consider if you can make any improvements in light of this situation to avoid and prevent such situations arising in future.

You will need to closely monitor the subsequent mental health condition of the student who was assaulted, in particular, and of the informant and other students. Maintain close contact with homestay families and the students’ families at home so that you can quickly react if they detect any worrying signs in the students’ mental health. Pastoral care representatives for the institution should also continue to monitor the affected students for any changes in academic performance, mood, physical appearance, or behaviour that might indicate mental health problems.

• Support for Sexual Abuse Survivors
• Rape Prevention Education

7. Earthquake

Case study; Earthquake

You are at work at your institution when a large earthquake strikes.

Your office is badly damaged, and once the shaking has stopped, you quickly make it outside with the other staff. There is widespread damage, sirens are blaring, and you’re concerned for your own family and how you will make it home.

Your institution’s international students are spread out across homestays and halls of residence, and you aren’t sure where they all are at the time the earthquake occurs. You have your cell phone, but not much else. The phone lines are completely engaged and you can’t get through to anyone.

‍ Secure your own safety first

The most pressing issue in this case is for you to look after your own safety. Hopefully, you and your family have an emergency plan that includes where to meet, as well as emergency supplies at home. Staff should have a grab-and-go bag at work with essential items like water, food, and walking shoes. Set a date for everyone at your institution to review and refresh the items in their go bag each year.

Communicating with students

Once you know that you and your family are safe, your next immediate concern is contacting your students to ensure they are safe, and to assess next steps. To effectively manage a complex situation like an earthquake or other natural disaster, planning is essential. Your international office should have a pre-prepared response plan that includes who in your office will be on the response team, where you will meet or how you will communicate (even if phone lines are down), and how information will be shared with international students and staff. 

Preparing students for a natural disaster is an essential part of this plan. In your orientation, you should ensure students know how to prepare their own emergency kit (or better yet - give them one), what to do if an earthquake strikes, and how/when to contact your office.

Once you have contacted your students and depending on the circumstances, make plans to either gather the students in one place or to regularly communicate with them if they are safer where they are. You will also need to liaise with homestay families and the halls’ management. 

Once you have adequate information about the students’ situation, communicate with their families, and establish when and how you will keep lines of communication open.

Information management

Another important aspect of your planning for natural disasters is information management. If your computer is at work and you cannot access it, you need a way to access student information quickly and easily via a cloud application from any device. Without this, you may be caught unable to reach out to your students, or to contact their emergency contacts.

Such a widespread and complex situation is likely to take substantial resources to manage, and staff will all be dealing with their own stresses and worries at home. Everyone involved is likely to need some level of mental health support, now and some time into the future.  

You’ll likely need to draw on any additional resources that you may have outside of the affected area, and this is worth considering before an incident like this happens, so you have a plan in place if it does.

It’s easy to see how difficult a natural disaster can be to manage, and how quickly resources can run out. Planning is absolutely essential. Use this scenario to think about what your institution would need in the event of an earthquake or other major natural disaster. How can you put together a robust plan that gives your staff what they need to respond to such an event? How can you ensure your international students are prepared?

• Ministry of Education - Planning and Preparing for Emergencies for Schools

8. Conclusion

We have chosen these critical incidents because they reflect real cases and represent some of the situations that institutions are most likely to face with international students. Some of the themes that run across these case studies are:

• the importance of forming a response team with clear roles and responsibilities
• the need for frequent and open lines of communication with all stakeholders 
• the consideration of privacy issues, and what information can be shared, when, and with whom
• the importance of looking after your own wellbeing by maintaining professional boundaries and adequately resourcing the response effort.

You can come back to these case studies regularly to review your emergency planning and policies and to train new staff when they are onboarded. Better yet - create your own bank of scenarios. After an incident occurs, write up a summary of what happened, how your team responded, what worked well, and what could be improved in the future. This bank of case studies can be used for team training in the future, to ensure your staff have non-specific problem solving skills, and to enable them to plan flexibly and manage a wide variety of incidents in the future.

9. References

• MoH Preventing Suicide
• WHO road safety report and ASIRT
• NAFSA Crisis Management for Education Abroad (US perspective)
• IEAA Managing Risk & Travel (Australian perspective)

• Journey Management
• Lone Worker Management
• Incident Reporting
• Hazard Identification
• Safety Observations
• Audits and Inspections
• Alertness Tracking
• Training Tracker
• Mining, Oil and Gas
• Manufacturing
• Construction and Engineering
• Transport and Logistics
• Health and Community Services

How to Write an Incident Report - With Examples

According to research on safety management among nurses (in hospital settings), "Despite 94.8% of registered nurses being aware of incident reporting systems, only 32% reported an incident in a month, indicating a critical gap between awareness and practical reporting practices in healthcare institutions."

It can drive severe consequences for overall safety in a workspace and shows that mastering the art of incident reporting is fundamentally integral to the effectiveness of your workplace safety and risk mitigation.

In this guide, you’ll learn the keys to:

• Optimizing the incident reporting process
• Crafting a detailed incident report
• Understanding the core elements of effective reporting
• Writing a compelling and structured narrative
• Adapting examples of incident reports for clarity
• How to find incident report forms tailored to your sector
• How the newest incident reporting software can change your approach

Equip yourself with the knowledge and the tools to transform your incident reporting from tedious form completion to a smart working environment. From basic principles to safety incident management software , your incident reporting toolkit is right here.

Incident Report And Its Purpose

An incident report is a formal written document that serves as a reference when an unexpected event or accident occurs. This event could result in injury, damage to property, or work interruptions. 

The main purposes of an incident report are to:

• Capture key details of what happened while events are still fresh in witnesses’ minds. It is the document of who, what, when, where, injuries/damage sustained, equipment/property affected, actions taken, and more.
• Allow a thorough investigation of the root causes and contributing factors that culminated in the incident. The more thorough your report, the more insight it provides on how and why the incident transpired.
• Identify any safety or operational policies violated that were part of the incident. It reveals if any protocols were not followed or were overlooked altogether.
• Inform subsequent action to prevent any similar incidents from occurring in the future. It will help management to see where they need to make improvements in processes, training equipment, policies, facilities, etc.

[ YOU CAN ALSO DOWNLOAD THIS FREE GUIDE TO EFFECTIVE WORKPLACE INCIDENT REPORTING ]

Core Components of an Effective Incident Report

Fundamental information.

The fundamental information outlined in an incident report includes:

• Type: Categorizing the incident provides a point of reference. Common types include injuries, property damage, security incidents, workplace violence, environmental problems, privacy breaches, and more.
• Location, date and time: The “where and when” of any incident is a must. Be as specific as you can with location, and with date and time.
• Names of individuals involved: List all people involved in the incident. Give the full name and any title or role, i.e., Robert Patterson, Security Guard. If there were injuries, list the person who was injured and list witnesses with their titles or roles, i.e. Alice Lansing, Accountant.
• Injuries sustained: Include a list of injuries, first aid that might have been administered, and any medical treatment. No injuries? State, "No injuries were sustained."

Specific Details

The specifics of an incident report provide important context:

• Equipment involved: Make a note of any tools, machinery, materials, chemicals or other equipment involved in the incident. Include the manufacturer, model number if it applies, and precise details of how the equipment was being used.
• Events leading up to the incident: The reconstruction of events can offer a number of insights into causes. Provide a concise chronological sequence of events leading up to the incident.
• Account of the incident: A detailed, chronological narrative of the incident itself will bring the incident to life. Use precise, objective language, quoting any witness statements where relevant.
• Subsequent events: Make a note of any actions that were taken after the incident, such as first aid, medical treatment, notification of the appropriate authorities, or checks for any damage or maintenance required on the equipment involved.

This leads to a basic account combined with vivid detail, making a full and useful incident report. The combination allows for the causes to be properly investigated and for the incident to be the basis for preventing similar eventualities.

Crafting an Effective Incident Report

A narrative structure is essential while writing an incident report. Organize the report into three basic sections:

Introduction

Who, what, where, and when should be answered in the introduction. As an example:

“Jane Doe, an ABC Company cashier, was involved in an incident around 10:15 am on Tuesday, March 1, 2022. The incident occurred in the company's headquarters breakroom at 123 Main St, Anytown, USA."

From here, we know that Jane Doe was involved, an event occurred, on Tuesday, March 1st, 2022, at 10:15 am, and in the breakroom at 123 Main St. It shows how this introduction sets the background for the report.

The body details the incident from beginning to end. It includes all relevant occurrences before, during, and after the incident.

As an example:

“Jane Doe walked into the breakroom and made her coffee at the coffee maker. As she reached for the coffee pot, she slipped on a puddle liquid and fell to the ground. The coffee pot struck her right calf and shattered. Jane Doe screamed out in pain with the fall.”

The body reaffirms who, what, where, and when, as well as the chronology.

The conclusion describes the resolution of the incident as well as key findings. As an example:

“Emergency services were called at 10:18 am. Jane Doe was removed by ambulance to Riverdale Hospital for a laceration of her right leg. She received 12 stitches. The broken coffee pot was cleaned and thrown away. Facilities were made aware and requested to keep a supply of Wet Floor signs positioned near breakroom spills.”

In the conclusion, the resolution and incident investigation recommendations are briefly stated to bring the matter to a close.

This introduction-body-conclusion structure makes incident reports logical and complete and makes them easy to understand. A story that winds its way to a conclusion makes a whole lot more sense.

Incident Report Example – How To Write It?

Here’s how an incident report will be written for “Main Office Security Incident - Unauthorized Entry Attempt”:

(This Incident report is vital, because it captures the security event and can be reviewed to make future security improvements.)

Other Examples Of Incident Reports [Manufacturing And Mining Industry]

Manufacturing Industry Incident Report Example:

Mining Industry Incident Report Example:

Incident Report Forms (For Different Organizations)

Reporting incident forms are the usual medium used to document incidents. They are tailored to the sector and the organization, so incident report forms differ. Here are a few examples:

General Staff Incident Report

These generic staff or personnel incident reports are employed by many businesses to log employee, customer, and visitor incidents. A general staff incident report generally includes:

• Person’s name and contact details
• Incident Time, date, and site
• Pertinent details about what happened
• Kind of injury or damage
• Name of witnesses
• Safety measures taken Suggestions for prevention

Here’s what a normal general staff incident report looks like:

Incident Report Construction Site

Construction job site safety guarantees in-depth incident reporting. Construction incident reports include particulars, for example:

• Name and role of person injured or involved
• Date, time, exact location, and description of incident
• Type of injury or illness sustained
• Equipment, materials, or chemicals involved
• Actions taken following the incident
• Suggestions to improve safety and prevent recurrences

A normally used construction site incident form looks like this:

Hospital/clinic Incident Report

Healthcare utilizes unique incident report forms to describe patient care, medical therapy, pharmaceutical errors, laboratory mishaps, confidentiality breaches, and a whole lot more. A healthcare facility or hospital might have an incident report that includes:

• Patient safety incidents, falls, infections, or privacy breaches
• Medication errors or equipment malfunctions
• Workplace injuries to staff
• Security issues, theft, property damage, or vandalism

Here’s a sample of patient incident report form usually used in clinical settings:

Incident Reporting Software For Smarter Workplace Management - SafetyIQ

SafetyIQ is an advanced incident reporting software that transforms incident reporting by providing a sleek, user-friendly platform that sets new industry standards for workplace safety.

Emerging as the leading incident reporting solution, SafetyIQ is redefining workplace safety with a variety of next-generation features and comprehensive free guides.

Take a closer look at the key features of this tool:

• Effortless Incident Reporting: The platform simplifies and centralizes the incident reporting process, allowing users to submit full-featured incident reports – complete with multimedia documentation – with minimal effort.
• Customization for Unique Needs: SafetyIQ tailors incident report forms to meet the unique requirements of each organization, expediting incident data capture and analysis in the process.
• Proactive Safety Measures: This platform is a host of specialized solutions for managing high-risk scenarios – Journey Management , Lone Worker Management , Fatigue Management , and beyond. It helps steer organizations beyond compliance and toward a proactive culture of safety.
• Real-time Insights and Analysis: Organizations enjoy a comprehensive suite of reporting dashboards that reveal the hidden safety performance insights within their data in real-time, featuring color-coded charts and infographics that allow for rapid identification of movements.
• User-Centric Design: The entire solution is designed with an emphasis on the end user, prioritizing a clean, user-friendly interface for both field workers submitting incidents and the managers analyzing the safety trends within their organization.

This software turns incident reporting into the beginning of a proactive safety culture by equipping organizations with the resources they need to put in place world-class safety practices continually. With its ability to assign corrective actions based on a data-driven approach, SafetyIQ is the best solution for workplace management and safety.

FAQs - Get More Answers Here!

Incident reporting software is a tool designed to streamline the documentation of untoward events or accidents in a business or workplace, which is crucial for reference, investigation, and informing corrective actions. It ensures a systematic approach to safety incident management.

SafetyIQ allows live incident reporting through its user-friendly platform, enabling real-time submission of multimedia-rich incident reports for immediate documentation and analysis of safety incidents.

SafetyIQ offers incident report templates that capture the critical information followed through a structured format, enabling consistency and completeness in incident documentation.

SafetyIQ has a user-centric design from the bottom up for an intuitive user experience that makes it easy for field workers to submit live incident reports and managers to analyze safety trends and overall enhance the incident reporting and management process.

Live incident reporting is simple and easy with the online platform. It enables the convenient and immediate submission of data-rich incident reports in real-time. Companies can customize the tool features to support unique requirements and enable proactive safety measures.

We cover a range of topics in our articles - view all blogs .

SafetyIQ’s journey management software can help to control the risks and protect your people. 

Journey management software program can allow employers to be instantly alerted when an employee has not checked-in.

From planning the journey, completing a risk assessment to gaining approval, the entire process is automated and seamless with SafetyIQ.

Get more actionable insights in your inbox!

Copyright © 2024 SafetyIQ Pty Ltd. All Rights Reserved.

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Blog Human Resources

How to Write an Effective Incident Report [Templates]

By Victoria Clarke , Jun 13, 2023

We all do our best to ensure a happy and healthy workforce. That’s why, in a perfect world, you would never have to create an incident report.

But since incidents do happen, it’s never a bad idea to be prepared for any situation–especially the unexpected.  

Small business owners, human resources teams and workplace emergency first responders: this is the article for you! 

In this step-by-step guide, I’ll share our top tips on creating incident reports that will help you carry out effective investigations and make sure similar (or more serious) incidents don’t happen again.  I’ll also include our top incident report templates to get the job done.

Table of Contents:

• What is an incident report?

What to include in a work incident report?

• How to write an incident report?
• Incident report examples, templates and design tips
• Simple incident report template
• COVID-19 employee incident report templates

All of the templates in this post can be customized using our easy online  incident report maker  tool. It’s free to sign up, many of our templates are free to use too.

What is an incident report? 

An incident report is a form to document all workplace illnesses, injuries, near misses and accidents. An incident report should be completed at the time an incident occurs no matter how minor an injury is.

Here’s one example:

Any illness or injury that impacts an employee’s ability to work must be noted. The specifics of what is required by law to be included in an incident report will vary depending on the federal or provincial legislation that affects your workplace.

If you’re unsure, you can take a look at your government’s website for more details. In certain cases, there are exceptions that can exempt small businesses from complying with such legislation. 

A well-structured incident report typically includes the following five key elements:

• Date, time and location: Provide specific details about when and where the incident occurred. This helps establish a timeline and context for understanding the event.
• Description of the incident: Clearly describe what happened, including relevant details such as the sequence of events, the people involved and any contributing factors. Use objective language and avoid assumptions or opinions.
• Witness information: Include names and contact information for any witnesses to the incident. Their accounts can provide valuable perspectives and corroborate details.
• Action taken: Outline any immediate actions taken to address the incident, such as first aid, evacuation procedures or contacting emergency services. Documenting these responses is crucial for understanding the effectiveness of the initial response.
• Recommendations for prevention: Offer suggestions on how similar incidents can be prevented in the future. This proactive approach demonstrates a commitment to improving safety and mitigating risks.

How to write an incident report ?

It’s important to establish a systematic method for investigating incidents.  

It’s also equally important to have a report prepared that enables you to record every relevant aspect of the incident details–this is the essential first step in the incident reporting process.  

After you’ve created your incident report form, you can: 

• Begin your investigation with fact-finding 
• And end your investigation with determining recommendations for preventing both an increase in the severity of the incident and the possibility of a recurrence.  

To write any incident case reports, follow the basic format described below.

1. Take immediate action 

Employees of your organization should notify their manager or another member of the company’s leadership committee as soon as an incident occurs–regardless of the nature of the event (whether it be an accident, illness, injury or near miss).  

That being said, there need to be communication channels clearly defined to promote the practice of employees coming forward in these situations and the importance of such.

Once an incident has been reported, the member of leadership’s first responsibility is to ensure that appropriate treatment, if necessary, is being administered to those affected by the event.  

On this note: if the hazard still exists, the manager that the event has been reported to must eliminate the hazard by controlling it. Each company should have a defined procedure for accomplishing this based on the nature of their work. 

For example, if there was a spill that caused a fall. You would attend to the victim and promptly have the spill wiped up and identify the area as a hazard by using a sign.

2. Collect the facts 

Once the immediate action including the response to the event and eliminating the hazard from the environment has been conducted, it’s time to determine and record the facts related to the incident details. 

9 facts related to the incident include: 

1. the basics.

Identify the specific location, time and date of the incident. This information is fundamental to the investigation and the most obvious information to collect. 

2. The affected

Collect details of those involved and/or affected by the incident. This would entail recording the name(s) of the individual(s) involved, their job title(s), the department(s) they operate in the manager(s) of those affected. 

3. The witnesses

Speak to any witnesses of the event to collect their perspectives of the event. Record their statements as detailed and accurate as possible in the form.  

To ensure accuracy, it’s best practice to review your notes with the witness to ensure they agree with how the event is portrayed in the report. It’s also important to include the name(s) of any witnesses in the report in case any additional questioning is required. 

4. The context

Consider and document the events that occurred leading up to the incident. Ask:

• What was the employee doing? 
• Who asked them to complete the task? How was the employee feeling prior to the incident? …etc. 

It is important to identify which factors were an outcome of the incident and which factors were present prior to the incident and could be a potential contributing factor to the incident occurring.

5. The actions

In the report, you must specify the actions of those involved at the time of the incident. What did the employee do that led to the incident? 

For example, if an employee injured their back when lifting a box at work, it is important to determine how that employee lifted the box to decide if that contributed to the injury. If yes, then inquire if this employee was trained properly for this task and by who or what source.  

6. The environment

Identify and record environmental conditions that contributed to the event. Was there inadequate lighting? Was a piece of equipment not operating properly? Was the employees’ visibility obstructed by a glare or blind spot? Etc. 

7. The injuries

Record detailed descriptions of specific injuries and evaluate the severity of such in the report. This description should include part(s) of the body injured, nature and extent of injuries. 

8. The treatment

It is also important to document in the incident case report the type of treatment administered for the acknowledged injuries. This information is important to document in order to understand how the employee recovers when reviewing the specifics of the event.

9. The damages

Record an account of any damage to equipment, materials, etc that was affected by the incident. This will be helpful to refer back during the analysis of the event in order to consider both a corrective action plan and to determine what items will need to be repaired or replaced. 

3. Analyze and reflect  

Collecting and recording the facts related to the occurrence of the incident will aid in determining how the incident occurred. Analyzing the collected facts related to the incident will aid in determining why the incident occurred. 

Analyzing and determining how and why the incident occurred is essential in order to develop an effective corrective action plan. 

Potential causes for accidents or injuries that occurred in the workplace could include: 

• Primary causes (for example, an unsalted ice patch on a set of stairs that caused a slip and fall). 
• Secondary causes (for example, an employee not wearing appropriate personal protective equipment, such as a hard helmet or eyewear).
• Other contributing causes (for example: a burned-out light bulb in the area causing poor visibility). 

4. Establish a corrective action plan 

A corrective action plan would provide recommendations as a means to reduce the possibility of a continued issue and/or recurrence of the incident details. The recommendations would result from an effective analysis of the facts collected and documented in the incident report. 

Elements of an effective corrective action plan could include: 

• Occupational Health & Safety training for employees 
• Preventative routine maintenance processes that ensure equipment is in proper working condition 
• A review of job practices and procedures with a recommendation for changes to reduce the risk of incidents 
• Conducting a job hazard analysis to determine if other potential hazards are associated with the task and/or environment and then training employees on these hazards based on the findings of the assessment 
• Engineering, equipment or PPE changes/upgrades to ensure the task or the process of completing said task poses less risk

Incident report examples and design tips

Here are some examples of types of incident reports to help you get started. I’ve also included some report design tips to help you present your information effectively. If you want to dig a bit deeper into the topic , here’s a comprehensive guide to general report design that I find handy.

Incorporate your branding into your report design

As with any document you create for your business, it’s good practice to incorporate your branding into your incident reports. (Psst– Venngage’s Brand Kit feature makes it easy to add your branding in just a click!) 

Include your brand colors in your design. You can do this by using them in the report header, footer, sidebar and in any visuals. 

You could use your brand colors in the background of your incident report:

You may also want to include your logo, like in this incident report template : 

Organize your information into sections using boxes

To make your information as readable as possible, organize it into sections. One of the easiest ways to do this is by using boxes.

For example, take a look at how these types of incident report templates use boxes to section off the information:

This type of incident report example also uses rectangles to denote section headers:

Color code the sections of your incident case report

Colors aren’t just great for making your reports , presentations and charts more interesting to look at. You can also use color to organize sections of your report and to draw attention to key information. 

For more tips on using color in your designs, read our guide on how to pick colors to communicate effectively .

Add a visual header to your incident report

As part of your company branding, you may want to add a visual header to your reports. For example, this incident case report template uses a neutral photo with a color filter to create a professional header:

You can do this in Venngage by overlaying a photo on a color background and adjusting the opacity of the photo: 

You can use the same effect for sidebars as well: 

Make a mock form to offer new team members as an example

If you’re transitioning in staff or something happens when the individual who owns incident reports is away, it’s very important that there is a process documented . That will ensure that if someone is put on the spot, they can fill in the incident report properly.

It can also be helpful to add brief descriptions of the information in the type of incident report to include in each field. Take a look at how this incident report example offers some brief text to guide the person filling it out:

Use icons to visualize concepts

Icons are small, compact visuals that can be used to reinforce the information in your reports. You can also use them to draw attention to specific fields and important pieces of information. 

For example, this incident case report template uses icons to indicate the purpose of each field:

• Preventative routine maintenance processes that ensure equipment is in proper working condition 

Incident report examples

Covid-19 employee incident report template.

Blue healthcare employee critical incident report template

Although being prepared for the unexpected is often difficult, preventative measures are the cornerstone of maintaining a happy and healthy working environment for yourself and your workforce.  

Incident reports are not only a defining piece in any company’s incident response protocol, but they provide a means to avoid recurring mishaps and/or inspire change. 

That’s why it is crucial to have a relevant and comprehensive incident report form prepared and on hand for any incident details that may arise. By adhering to your jurisdiction’s legislation and considering the four components prescribed above, you’ll be well-prepared to handle incidents effectively.

The effect of responding to workplace incidents in a timely and detail-oriented manner will not only ensure a safe workplace but also: 

• Reassure your employees that their employer is prepared to take the right steps in any situation 
• Ensure all appropriate parties are fully informed of incidents 
• Establish a record of incidents for future reference 
• Protect both you/your company and your employees from lawsuits and disputes

FAQs about incident reports

What is the purpose of incident reporting.

An incident report is used to describe an event that requires an investigation that needs to be documented.

Types of incident reports

• Accident Reports
• Workplace Incident Report

What are the 4 types of incidents?

Commonly, incidents can be categorized into four main types:

• Accidents: Involving unintended harm, damage or injury.
• Near Misses: Situations where an accident could have occurred but was narrowly avoided.
• Unsafe Conditions: Reports about hazardous or unsafe environments that need attention.
• Unsafe Acts: Documenting incidents involving violations of safety procedures or rules.

Incident reports generally cover a variety of situations and the specific types may vary based on context and industry. It’s important to note that these categories can overlap and the classification may differ depending on the reporting system or industry standards.

More HR guides and templates:

• 12 Powerful Performance Review Examples (+ Expert Tips By an HR Manager)
• 17 Essential Human Resources Poster Templates

Real Examples of Incident Reports at the Workplace with Templates

Accidents can happen, no matter how many preventative measures are in place. And, when accidents do happen, it’s vital to learn from them. To ensure your documentation is spotless, it’s always a good idea to look at some example incident reports at the workplace.

A safety incident report helps ensure nobody is subject to mistreatment because it contains information from the injured employee as well as eyewitnesses. This helps fill in missing pieces of information and figure out how the accident occurred exactly. 

“The safety of the people shall be the highest law.” Marcus Tullius Cicero

So, let’s dive in! 

If you’re looking for an example of an incident report at the workplace, feel free to jump to that section using the links below. Otherwise, we will first discuss what incident reports are and why they are so important.

What is a Workplace Incident Report? 

A workplace incident report is a document that states all the information about any accidents, injuries, near misses, property damage or health and safety issues that happen in the workplace. 

They are very important to identify the root cause of an incident along with any related hazards and to prevent it happening again in the future. As soon as an incident takes place and everybody in the workplace is safe, a work incident report should be written up. 

Typically, a workplace accident report should be completed within 48 hours of the incident taking place . The layout of an accident incident report should be told like a story, in chronological order, with as many facts as the witnesses can possibly remember. 

What should you include in an incident report?

There are many different types of incident reports, depending on your industry, but most will include the underlying details listed below in order to understand what happened: 

• The type of incident that took place
• Where the incident happened
• The date, day and time of the incident
• Names of the people involved
• Injuries that were obtained 
• Medical treatment that may have been required
• Equipment that was involved
• Events leading up to the incident that could have contributed to it taking place
• Eyewitnesses that can tell their side of the story

For example…If a chemical was involved in the incident, it should be noted if the victim was wearing appropriate PPE or not, as well as a photograph of the damage and the chemical’s label stating its components. If a workplace vehicle was involved, all information about the vehicle should be noted, and the possible reasons why it occurred if there is no clear answer. Employers should ensure vehicle safety guidelines are adhered to in order to prevent incidents in the workplace. 

If this is an OSHA recordable incident (accident) and the company is exempt from OSHA recordkeeping , the employer must also fill in OSHA Form 300 . This form enables both the employer and the agency to keep a log of the injuries or illnesses that happen in the workplace. It includes crucial information such as the number of working days missed due to injury, the sort of injury that was obtained and if medical treatment was necessary. 

How to Write an Incident Report

It is important to lay out an incident report clearly and concisely with all the relevant information about what happened. The clearer it is to read, the easier it will be to understand the cause of the workplace accident. 

The language used for incident reporting should not be too emotional and should not purposefully put the blame on someone. Here is an incident report example template:

This workplace incident report template includes the basic guidelines and best practices of what to include to make sure the report includes all the details it should. Once a report is written, it should be kept on record in the workplace. 

Incident Report Examples

Depending on the type of workplace incident, the writer will need to include various pieces of information. If you are not sure how to write an incident statement, here are example incident reports for the workplace covering various scenarios. 

Injury Incident Report Example

“At 11.20am on Tuesday 7 th July 2020, a worker, Timothy Johnson, tripped over an electrical wire on the Blue & Green construction site, located on Main Street, Riverside. He was carrying a hammer at the time. 

It is believed the wire should not have been stretched across the ground without safety tape securing it to the ground and drawing attention to it. Timothy fell to the ground and dropped the hammer but did not injure himself with it. He twisted his ankle, which immediately began to swell and scrapped the side of his leg in a minor way. A co-worker came to assist Timothy to his feet and helped him walk to a nearby bench. Timothy could not put his weight on his left foot, so he was taken to a nearby hospital. Once at the hospital, doctors confirmed that Timothy had sprained his ankle and would have to keep the foot elevated and use crutches for the next two weeks. He would not be able to work during this time. 

The foreman for the construction site has assessed the wires on the ground and concluded that brightly colored tape should secure the wires to the ground to draw attention to them and to ensure there are no bumps in the wire that are easy to trip over so that this does not happen again”.

Forklift Accident Report Sample

“On Friday 5 th July 2020, at 3.35pm, a forklift driver, Max White, was driving the forklift he usually drives in the Sunny Side Warehouse, ABC Street, when the front right tire got caught on a piece of wood on the ground, causing the forklift to overturn with Max inside it. 

Luckily a co-worker was nearby to help Max climb out of the right side of the forklift. Max was shaken up and reported that his left shoulder and left side of his neck were hurting him from the impact. Max decided he did not need to go to the hospital as he felt like he would only obtain bruises from his injuries and that they were not severe enough to need medical attention. His manager sent him home for the rest of the day to ensure he did not strain himself further. 

The wood that caused the forklift to overturn had not been stacked properly and has now been moved to a secure location in the warehouse to make sure it does not cause any more issues for forklift drivers”.

Fall Incident Report Sample

“In Fairview Boutique on Friday March 6 th , 2020, Samantha Wright was stacking shelves while standing on a ladder in order to reach the top shelf of handbags at 4.10pm. As she was stretching to place a bag on the shelf, the ladder collapsed from under her and she fell to the ground. Her co-worker heard the loud noise and immediately helped her. Samantha was in a lot of pain and could not get to her feet as she felt lightheaded. An ambulance was phoned, and she was brought to hospital. Samantha obtained a broken right arm, bruised thigh and hip, and a bump to the head that left no major head injury. She was recommended three weeks off work at the minimum by doctors.  The fall was concluded to be of nobody else’s fault but was put down to Samantha accidently overreaching instead of moving the ladder to where she needed to see”. 

Hand Injury Incident Report Sample

“On April 21 st , 2020, at Willow Maintenance, Yellow Abbey Grove, Kyle Jenkins was about to use a miter saw to cut some timber, but when he started to use the saw, it jolted, causing the saw to come down suddenly on his hand. 

Kyle’s left thumb was cut deeply by the saw and he lost a lot of blood. Co-workers came to his aid, turned the saw off and helped him stop the bleeding with tissues. He was then brought to the hospital where he received eight stitches and was told to not use the hand for rigorous work for 4 weeks. The head of Willow Maintenance inspected the saw to check for any issues and see why it came down and cut Kyle’s hand. It appeared that whoever was the last person to use the machine did not put the safety latch back on the saw once they had finished using it. 

If this safety latch was on the saw when Kyle used it, it would not have cut his hand, but rather, automatically shut off once it jolted. The manager decided to take a day to retrain his staff to ensure they adhere to the health and safety guidelines of the company”. 

Exposure Incident Report Sample

“In Woodbell factory, Springville, on Tuesday May 26 th , 2020, Annie Bedley was packaging household cleaning products when a bottle tipped over onto her wrist. 

She got up from her seat to wash off the chemical in the washroom. She then went to her supervisor to show her what had happened. Annie’s wrist was red and itchy but was not burning as she had washed off the remnants of the chemical immediately. Annie’s supervisor brought her to the office to sit with a cold compress on her hand and applied a layer of ointment to treat the burn. Annie did not feel like she would need further medical assistance and agreed with her supervisor that she would need two to three days off work to ensure the burn did not get irritated. 

Annie was wearing appropriate PPE at the time of the incident and no faults were found on the conveyor belt at the packing bay. The incident has been noted as an accident with nobody to blame. Photographic evidence of the burn has been included in this file”.

First Aid Incident Report Sample

“On Friday November 15 h 2019, Arthur Stokes was walking along the corridor between building four and five of Graygrock Inc. when he noticed that there was something sharp sticking through the bottom of his right shoe. 

He stopped to see what it was and found a nail stuck in his shoe. He took his shoe off and lucking was able to pull the nail out as it hadn’t pierced through to his foot and only minorly scraped it. He saw the stairwell was getting new handrails fitted and presumed the nail came from that. He saw two other nails further along the corridor and decided to pick them up to make sure nobody else stood on them. He reported to his manager’s office where he presented the nails and explained the situation. His foot had a small cut, so Arthur’s manager gave him an anti-septic wipe and a band-aid to help him. 

Arthur returned to work while his manager talked to the construction workers about keeping their workspace neat and to prevent any further accidents like this from happening”. 

Incident Report Form Templates

The layout of an incident report forms can vary depending on where the incident took place and the type of injuries. Here are some examples of incident reports at the workplace that you can use. 

Incident Report Form for General Staff (Word/PDF)

This general staff accident report form template can be used in a variety of workplaces. It includes all the necessities to describe a workplace incident to ensure it is recorded correctly. This general form is ideal for any business type. 

Incident Report Form for a Construction Site

This example incident report for the workplace is unique to others as it includes a field for the construction project name and the project manager’s details. This makes it easy to understand where in the construction site the accident occurred and how severe it was.

Incident Report for a Hospital/ Medical Clinic (Word/PDF)

The hospital incident report template is much more detailed than others as it must include accurate information about the staff member or patient’s injuries, where in the hospital it happened and what medical treatment they required.

As you write your workplace incident reports, remember it is not to place blame on one person, but rather record a series of events that have taken place. Sometimes these are pure accidents due to bad luck and, sometimes, there is human error or a technical fault involved. By the way, this is the basis of the Just Culture Algorithm™ which is definitely worth exploring if you’re looking to improve the safety culture at your workplace .

These examples of incident reports at the workplace are only the tip of the iceberg when it comes to the variety of workplace accidents that can occur. In any case, it’s crucial to record any incidents that arise because this helps create a safer work environment.

References & Further Reading

• OSHA’s Guide for Employers carrying out Incident Investigation
• OSHA’s Injury & Illness prevention Program
• Workplace Injury Information
• Eyewitness Statement Form : Should be included for any eyewitnesses to the incident to aid the investigation.
• Injury Investigation Questions : Should be asked when an employee has been injured at the workplace to understand exactly what happened.
• Incident Investigation Flowchart Procedure: A step by step example of the procedures involved in carrying out a workplace incident investigation.  

Related Posts

The 18 near miss reporting examples you need to know.

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BSAFE INCIDENT CASE STUDY 09: FALL OF A HEAVY OBJECT

Published: 29 July 2021

Two crew members on a general cargo ship were injured when a suspended load fell and struck them. The suspended load were wire rope legs and shackles used to move the ship’s hatch covers (“the lifting gear”), which fell because the hoist parted (Figure 1) after one of the shackles became wedged at the storage location. Both crew members were standing inside the hazardous area around the suspended load, ready to manually guide the load clear of snagging hazards during the lift. The lifting gear had been stowed in the cargo hold ventilation duct space, where it was known to have snagged before. The lifting operation had not been formally risk assessed, and a lifting plan for the work had not been produced.

WHAT HAPPENED?

A 11,000 GT general cargo ship built in 2018, was to load a cargo of wind turbine tower sections ( Figure 2 ). The deck crew, supervised by the chief officer (C/O), began to prepare the ship for cargo loading. This work was halted in the afternoon due to adverse wind conditions, but was scheduled to recommence later in the evening when the weather was expected to improve. At 2100 the weather had improved. The C/O conducted a safety briefing and took up the position as supervisor, accompanied by the bosun (BSN). The ship’s working lights were turned on, illuminating the area where the crew were to work.

Following the safety briefing, one of the able-bodied seamen (A/B) used the ship’s forward crane to remove the cargo hold ventilation duct space cover ( Figure 3 ), so that the lifting gear could be retrieved. Two other A/Bs then entered the ventilation duct space and attached the first of two hatch cover lifting gear sets to the crane’s hook using a fibre sling ( Figure 1 ). Both A/Bs then climbed out of the space and stood close to the hatch edge ready to guide the load and free any snags as it was lifted.

There was no designated storage space for the lifting gear on board. The lifting gear had been stowed on wooden pallets positioned on top of the ventilation duct coamings in the ventilation duct space ever since delivery by the shipbuilder. The lifting gear was made up of two slinging sets; each set weighed 0.6t and consisted of two 17m long, 52-millimetre (mm) diameter, wire rope legs joined together with a master link ( Figure 4 ). Each wire leg had a shackle attached to an eye at the lower end.

Using a radio, the C/O instructed the A/B controlling the crane to commence lifting. After the load had been lifted about 2-3 metres, the gear snagged. The C/O ordered the crane driver to stop hauling and the two A/Bs on deck freed the snag by hand. With the two A/Bs remaining close to the edge of the hatch the C/O ordered the crane driver to start heaving again.

Shortly after the lifting operation recommenced, a shackle at the lower end of the load became snagged on a ventilation trunk coaming ( Figure 3 inset). The C/O immediately instructed the crane driver to stop, but at the same time the fibre sling parted and the lifting gear fell to the deck, striking both A/Bs.

One of the A/Bs suffered a severe head injury while the other suffered a minor hand injury. Other crew members administered first aid and raised the alarm. Ambulance paramedics were soon on the scene and treated both A/Bs before transferring them to a local hospital. The A/B who had suffered  the serious head injury was later transferred to a dedicated neurological injury unit, before eventually being repatriated.

After the accident the parted sling ( Figure 1 ) and five other similar slings from the ship were examined at an expert testing centre. The report of these tests stated that all six slings would have failed a visual inspection as they were soiled and had illegible identification markings.

Further details about the incident and the lessons learned are provided in the summary of the case study.

In addition, a presentation and reflective learning form have been prepared based on the incident as suggested training materials. These can be used by Members or their crew in any way they see fit to encourage reflection and gain the maximum learning from this incident: to consider why the incident happened; “what it means to me”, and to then relate the identified learning points to one’s own personal situation.

Finally, a Britannia commentary on the incident has been prepared which discusses the key points in more detail in order to help develop the reflective learning from the case study.

CASE STUDY MATERIAL

BSAFE INCIDENT CASE STUDY NO.9 – SUMMARY

BSAFE INCIDENT CASE STUDY NO.9 – REFLECTIVE LEARNING FORM

BSAFE INCIDENT CASE STUDY NO.9 – PRESENTATION

BSAFE INCIDENT CASE STUDY NO.9 – BRITANNIA COMMENTARY

LESSONS LEARNED

The following lessons learned have been identified. These are based on the information available in the investigation report and are not intended to apportion blame on the individuals or company involved:

• The deck preparations had been delayed by weather and there was pressure to prepare the ship for the cargo loading.
• The operation was not stopped by any of the involved crew when the A/Bs positioned themselves close to the suspended load.
• The ship’s SMS did not contain a risk assessment or a procedure for the stowage and handling of the hatch cover lifting gear, nor any guidance for the conduct of a lifting plan and the identification of fall zones.
• With no procedure to follow, the crew had adopted their own method of carrying out the lifting operation. The crew had experienced similar snagging events on previous occasions. When these had occurred, the deck crew had manually freed the gear after the crane had stopped hauling. No Near Miss report or corrective actions followed.
• The ship had not been built with a dedicated storage area for the hatch cover lifting gear. In result, the crew had devised a local storage arrangement which might have appeared appropriate, however had a significant number of potential snagging hazards. This storage arrangement had not been subject to a formal risk assessment.
• The load fell because the synthetic fibre sling used to lift it parted under tension. Although the sling’s nominal SWL was more than twice the weight of the load being lifted, the sling was in a poor condition and should have been discarded.

For more information on this incident email [email protected] .

THIS CASE STUDY IS DRAWN FROM THE INVESTIGATION REPORT 11/2020 PUBLISHED BY THE MARINE ACCIDENT INVESTIGATION BRANCH (MAIB).

THE PURPOSE OF THIS CASE STUDY IS TO SUPPORT AND ENCOURAGE REFLECTIVE LEARNING. THE DETAILS OF THE CASE STUDY MAY BE BASED ON, BUT NOT NECESSARILY IDENTICAL TO, FACTS RELATING TO AN ACTUAL INCIDENT. ANY LESSONS LEARNED OR COMMENTS ARE NOT INTENDED TO APPORTION BLAME ON THE INDIVIDUALS OR COMPANY INVOLVED. ANY SUGGESTED PRACTICES MAY NOT NECESSARILY BE THE ONLY WAY OF ADDRESSING THE LESSONS LEARNED, AND SHOULD ALWAYS BE SUBJECT TO THE REQUIREMENTS OF ANY APPLICABLE INTERNATIONAL OR NATIONAL REGULATIONS, AS WELL AS A COMPANY’S OWN PROCEDURES AND POLICIES.

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• Am J Case Rep

Severe Traumatic Brain Injury: A Case Report

Clinton g. nelson.

1 Department of Trauma Surgery, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, U.S.A.

2 Department of Neurocritical Care, HonorHealth John C. Lincoln Medical Center, Phoenix, AZ, U.S.A

Jeanette Bannister

James dzandu, alicia mangram, victor zach.

Patient: Male, 28

Final Diagnosis: Closed head injury

Symptoms: Bilateral mydriasis • coma

Medication: —

Clinical Procedure: Ventriculostomy and hemicraniectomy

Specialty: Neurology

Unusual clinical course

Background:

Traumatic brain injury remains a challenging and complicated disease process to care for, despite the advance of technology used to monitor and guide treatment. Currently, the mainstay of treatment is aimed at limiting secondary brain injury, with the help of multiple specialties in a critical care setting. Prognosis after TBI is often even more challenging than the treatment itself, although there are various exam and imaging findings that are associated with poor outcome. These findings are important because they can be used to guide families and loved ones when making decisions about goals of care.

Case Report:

In this case report, we demonstrate the unanticipated recovery of a 28-year-old male patient who presented with a severe traumatic brain injury after being in a motorcycle accident without wearing a helmet. He presented with several exam and imaging findings that are statistically associated with increased mortality and morbidity.

Conclusions:

The care of severe traumatic brain injuries is challenging and dynamic. This case highlights the unexpected recovery of a patient and serves as a reminder that there is variability among patients.

In the United State alone, there are approximately 1.5 million traumatic brain injuries (TBI) per year, and TBI is the leading cause of death among individuals under the age of 45 [ 1 , 2 ]. Annually, these injuries result in approximately 50 000 deaths and about 80 000–90 000 cases of debilitating head injuries [ 2 ]. In the US, the estimated annual economic cost of TBIs is $76.5 billion, and we must not forget the emotional and physical toll that disability inflicts on patients and their families [ 3 ]. In many cases, patients are left without the ability to work or to perform activities of daily living (ADLs) [ 4 ]. Initial management of TBI is the most critical time period because it will have the greatest effect on mortality and degree of debility that surviving patients will experience.

In TBI, the most important tool used to assess degree of brain injury and prognosis is exam findings. According to the guideline Early Indicators of Prognosis in Severe Traumatic Brain Injury , on average, 88% of patients who presented with bilaterally un-reactive pupils became vegetative or died, and 4% had good recovery or moderate disability [ 5 ]. The Glasgow Coma Scale (GCS) uses exam findings to quantify level of consciousness following TBI, with 3 being the worst, defined as deep coma or death, and 15 being the best, a fully awake person. In a study by Fearnside et al., out of 315 patients with severe TBI, 65% with initial GCS of 3 died [ 6 ]. In a larger study by Marshall et al., out of 746 patients, 78.4% with initial GCS 3 died and 7.2% had mild to moderate disability [ 7 ].

Radiographic findings can also be used be used to predict morbidity and mortality, and can be used to guide surgical intervention. A review of 753 computed tomography (CT) studies that revealed abnormal mesencephalic cisterns, midline shift, and subarachnoid hemorrhage were associated with an increased risk of elevated intracranial pressure (ICP) and death [ 8 ]. Here, we describe a patient who had all of the above CT findings, and who presented with a GCS of 3 and bilaterally dilated and fixed pupils.

Case Report

Bystanders found a 28-year-old, unhelmeted, white male prone and unconscious after he had lost control of his motorcycle and went off the road. He was brought to the Emergency Department via ambulance intubated as a Level 1 Trauma activation. The physical examination revealed a GCS of 3T, 4 mm bilaterally fixed pupils, negative corneal response, right parietal cephalohematoma, and cerebral spinal fluid (CSF) otorrhea on the right. CT of the head showed subarachnoid hemorrhage with left frontal and temporal subdural hemorrhage ( Figure 1 ), effacement of the suprasellar cistern ( Figure 2 ), and effacement of the 3 rd and 4 th ventricles ( Figure 3 ). In addition, CT studies showed a left frontal/temporal and parietal hematoma with mass effect and cerebral edema causing a 5.38-mm left to right midline shift ( Figure 4 ), a frontal skull base fracture, and a complex non-displaced comminuted fracture of the right temporal bone. He was bradycardic, with his lowest heart rate recorded at 28 bpm, and hypertensive with an initial blood pressure of 172/118 mmHg and markedly elevated blood pressure of 221/105 mm Hg 30 min after his arrival at our facility. He required atropine push and nicardipine infusion. An arterial line and central venous catheters were placed for fluid and medication administration. Emergent treatment for herniation syndrome included endotracheal intubation, 30 grams of IV Mannitol, hypertonic solution of 23% (weight/volume) sodium chloride (NaCl), and left-sided decompressive craniectomy. Postoperatively, an external ventricular drain (EVD) was placed; the initial intracranial pressure (ICP) was 14 mmHg. The patient was examined postoperatively and also after EVD placement. His GCS was 5T, with bilaterally reactive pupils, and positive corneal reflex in the left eye. CT of his head showed improvement of midline shift ( Figure 5 ) and the ventriculostomy catheter tip was found to be in the proper location in the frontal horn of the right lateral ventricle ( Figure 6 ). The patient was then started on 3% NaCl continuous infusion. ICP and cerebral perfusion pressure (CPP) displayed normal values at 3–4 and 70–75 mm Hg, respectively, for the first 24 h with the EVD open at 10 cm H 2 O.

10/30/14 Presenting Head CT showing traumatic subarachnoid hemorrhage in sylvian fissure and left frontal and temporal subdural hemorrhage.

10/30/14 Presenting Head CT showing effaced suprasellar cistern and left temporal subdural hemorrhage.

10/30/14 Presenting Head CT showing cerebral edema with effacement of third ventricle, bilateral traumatic subarachnoid hemorrhage, and left frontal/temporal subdural hematoma.

10/30/14 Presenting Head CT showing left frontal and parietal subdural hematoma, bilateral traumatic subarachnoid hemorrhage, and cerebral edema worse in left hemisphere with 5.38 mm of left to right midline shift.

10/30/14 CT head after left craniectomy for decompression showing improved midline shift and evolving bilateral traumatic subarachnoid hemorrhage.

10/30/14 Head CT after ventriculostomy showing catheter tip in frontal horn of right lateral ventricle.

On hospital day (HD) 2 the patient’s ICP was elevated in the upper 20s in the setting of shivering, hypertension, and fever, which were controlled with increased sedation, nicardipine infusion, and targeted temperature management, respectively. Repeat CT revealed cerebral edema in evolution, with no worsening midline shift or hemorrhage.

On HD 3 his GCS improved from 6T to 8T, with intact brain stem reflexes. The next day, HD 4, the patient’s oxygen saturation dropped from 96% to 87% requiring an increase in fraction of inspired oxygen (FIO2) from 50% to 80% and positive end-expiratory pressure (PEEP). Respiratory cultures were obtained and a chest x-ray revealed worsening bibasilar opacities ( Figure 7 ); therefore, he was empirically started on IV vancomycin.

11/1/14 Chest x-ray showing bilateral interstitial infiltrate and left base atelectasis and pleural effusion.

On HD 5, the patient’s GCS deteriorated from 8T to 3T in the setting of elevated ICP. During bronchoscopy, his ICP was noted to be markedly elevated at 46; therefore, 23% NaCl was administered intravenously over a period of 10 min. Subsequently, a repeat CT of the head was obtained that showed cerebral edema in evolution and no change in midline shift or hemorrhage. Respiratory cultures on HD 6 revealed methicillin-sensitive staphylococcus aureus (>10 000 cfu/ml) and pseudomonas aeruginosa (>10 000cfu/ml). Repeat chest x-ray showed worsening infiltrates and bilateral pleural effusions ( Figure 8 ). The antibiotic was switched from vancomycin to IV levofloxacin and IV cefepime.

11/4/14 Chest x-ray showing worsening interstitial and alveolar infiltrates and pleural effusions bilaterally.

Examination on HD 8 revealed an improved GCS of 6T. His ICP was controlled during an EVD clamp trial, and the EVD was then removed. There were also copious amounts of thick, tan endotracheal secretions; therefore, another bronchoscopy was performed using saline lavage. The patient was started on IV Zosyn and cefepime was discontinued. ICP was controlled by administering 23% NaCl. During a sedation vacation, his oxygen saturation decreased from 95% to 70% and the ventilator settings were therefore changed to airway pressure release ventilation (APRV) mode.

On HD 14, his oxygenation was improving and remained stable at 97%. The ventilator mode was weaned from APRV to continuous mandatory ventilation (CMV). The patient was taken off sedation. His GCS was 10T and he was started on amantadine. He was started on oral metronidazole due to multiple loose stools positive for Clostridium difficile toxin B.

On HD 15, he began blinking to threat, with a GCS of 10T. A CT of his head showed improvement in diffuse cerebral edema and effacement of basal cisterns ( Figure 9 ). He underwent a percutaneous tracheostomy with video-assisted bronchoscopy, and open gastrostomy tube placement by trauma surgery. The patient remained neurologically unchanged on HD 16, but repeat chest x-ray revealed an interval increase in right-sided infiltrates with resolution of left lung opacity. On HD 17, he continued to maintain adequate oxygen saturation at 97% and was started on continuous positive airway pressure (CPAP).

11/14/14 New left occipital horn intraventricular hemorrhage, increased external herniation of left frontal contusion, and resolving diffuse cerebral edema with decreased effacement of third ventricle.

On HD 18 the patient developed tachypnea and he was placed back on CMV. The antibiotics were changed from Zosyn to levofloxacin and nebulized tobramycin due to piperacillin/tazobactam-resistant Pseudomonas pneumonia. On HD 19 his neurologic status was unchanged and he was started on Provigil. He was also given a protective helmet. Two days later, on HD 21, the patient’s neurologic status remained unchanged and he was discharged to a long-term care facility.

A follow-up visit three months later revealed the patient was living at home with his mother. In the interim his tracheostomy and gastrostomy tube had been removed. His major neurologic sequelae were transcortical motor aphasia and mood disorder. His GCS was 13 (E4, V3, M6). His GOS, on a 5-point scale, was 3, with severe injury and permanent need for help with daily living. His Modified Rankin Scale was 3 with moderate disability, requiring some help, but able to walk without assistance. His Lawton Instrumental Activities of Daily Living Scale was 4/8. Barthel Index was 95/100, and National Institutes of Health Stroke Scale was 5. Eleven months after the accident, he had similar outcome scores and had developed a seizure disorder; however, his speech was markedly improved with speech therapy. A repeat CT of the head showed improved external herniation ( Figure 10 ).

8/3/15 Improved external herniation and increase in hydrocephalus secondary to prior brain injury.

When predicting mortality and unfavorable outcome following TBI, exam, laboratory, and imaging findings can be used together by utilizing the CRASH and IMPACT calculators [ 9 , 10 ]. Unfavorable outcome is described as death, vegetative state, or severe disability. Here, we describe a patient who presented with a GCS of 3, bilaterally fixed pupils, and CT findings of subarachnoid bleeding, midline shift, subdural hematoma, effaced 3rd ventricle, effaced 4 th ventricle, and effaced basal cisterns. Therefore, according to the CRASH calculator, which takes into account country, age, GCS, pupil reactivity, and CT findings, he had a 14-day mortality risk of 91.8% and a 95.7% chance of unfavorable outcome at 6 months [ 9 ]. His pertinent laboratory studies, which are utilized along with exam and imaging findings in the IMPACT calculator, revealed an initial glucose concentration of 260 mg/dL and a hemoglobin concentration of 15.4 g/dL. Using the IMPACT calculator, at 6 months, the patient’s predicted probability of mortality was 62% and the probably of unfavorable outcome was 77%. He left our facility bedbound, ventilator- and tube feed-dependent, and in a minimally conscious state with a GCS 10T. Yet despite all this, he had a favorable recovery. Within 1 year of discharge he was able to live at home, interact, and go shopping with his mother, walk, feed himself, and perform simple chores and ADLs.

This is a poignant reminder that variability between individual patients makes prognosticating after traumatic brain injury difficult and uncertain.

Conclusions

Our case shows that severe caution should be taken when using prior studies to make medical decisions about individual patients. Treatment of traumatic brain injuries is complex, and should continue to evolve with evidence-based medicine. Improvement in outcome is not based on 1 intervention; rather, it is the additive effect of multiple interventions. It is possible that the addition of multimodality monitoring could have further changed his outcome, and more studies need to be done to answer this. In addition, daily multidisciplinary rounds with Neurocritical Care, Trauma Critical Care, Infectious Disease, Pharmacy, Respiratory Therapy, Physical Therapy, Occupational Therapy, Social Services, Chaplain Services, and Dietary Services provided optimal medical management in a team-based approach. Further studies need to be conducted to explore the effect that daily multidisciplinary rounds have on the outcome of severe TBIs.

Abbreviations

The authors whose names are listed within this manuscript certify they have no affiliations with any organization or group with any financial or non-financial interest in this report.

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Construction Incidents Investigation Engineering Reports

This webpage includes forensic engineering investigation reports of catastrophic incidents conducted by the Occupational Safety and Health Administration (OSHA), Directorate of Construction – Office of Engineering Services. Many of these incidents resulted in one or more worker fatalities, and property loss, lawsuits, or settlements of millions of dollars. Each investigation was performed at the request of an OSHA field office or State Plan OSHA as part of an enforcement inspection. These reports may include professional opinions of the investigating engineer; incident root cause opinions; factual data; and findings.

These investigative reports were prepared to assist the OSHA field office or State Plan OSHA. The alleged violations of standards referenced in the reports are findings and recommendations of the investigating engineer to assist the requesting office. The violations and findings recommended in the report does not constitute an OSHA violation of a specific party named in the report. The OSHA field office or State Plan OSHA may issue the recommended violation; additional and/or different violations of standards to the appropriate party. The final resolution of the enforcement case may result in changes to the initial proposed alleged violation(s).

The intent of these reports is to help employers, workers, construction engineers, project managers, and regulatory bodies identify problems in construction design, project management, and management of field engineering changes. Hopefully, this information will help reduce future incidents, fatalities, and serious injuries.

The web-version of the report may not include all photographs, schematics, computations, tables, figures, and other non-text items. Otherwise, the text of each report is identical to the original report. The report is maintained as part of the OSHA enforcement case file in the appropriate Area Office or State Plan.

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May 2022: Investigation of the November 8, 2021, Partial Collapse of Wood Roof Trusses during Construction of Dollar General Store, Orange City, Florida

Wood roof trusses collapsed during installation and fell onto the ground floor where a Dollar General store was under construction. The roof framing consisted of 66 wood piggyback base trusses spanning 70 feet. Two employees were injured after falling approximately 12 feet and a third employee cutting lumber inside the building, was fatally crushed by the falling trusses.

December 2021: Investigation of the April 14, 2021, Collapse of a Bridge Span under Demolition, Herbert C. Bonner Bridge, Dare County, NC

The last span of the Herbert C. Bonner Bridge (Bonner Bridge) under demolition collapsed in Dare County, North Carolina. An employee engaged in the steel cutting, was killed. The collapsed span was the navigation span of the Bonner Bridge measuring 180 feet long, 24 feet wide, and approximately 60 feet above sea level.

July 2020: Investigation of the January 10, 2020, Scaffold Collapse in Saipan, Commonwealth of the Northern Mariana Islands

Three employees were working on a scaffold attached on the fourth floor of a hotel, when the cables supporting the scaffold suddenly failed and the scaffold collapsed. The scaffold, approximately 17 feet long and 15 feet wide, was attached to the building and was being used to transfer materials into the building. At the time of the collapse, the employees were moving materials from the scaffold into the building. The employees and materials fell 10 feet to the concrete floor below resulting in three employees being injured.

July 2019: Investigation of March 15, 2018 Pedestrian Bridge Collapse at Florida International University, Miami, FL

A pedestrian bridge under construction collapsed and fell over the SW 8th Street near SW 109th Avenue in Miami, Florida. The bridge was being constructed to connect the FIU campus with the City of Sweetwater. The bridge, at this stage of construction, consisted of a single concrete truss spanning approximately 174 feet and weighed approximately 930 tons. The concrete bridge was cast at a nearby off-site location and then transported to its final location. At the time of the collapse, motorists were waiting underneath the bridge for the traffic light. One employee and five motorists were fatally injured, and another employee permanently disabled.

October 2018: Investigation of the April 19, 2018, Communication Tower Collapse in Fordland, Missouri.

The project involved the reinforcement of the KOZK 1,891-foot-tall guyed communication tower just north of Fordland, Missouri. The tower required structural modifications to support the transmission line replacement. However, the suggested diagonal replacement procedure was flawed in that it compromised the effectiveness of the integrated surrounding braces and the load bearing capacity of the tower legs. At the time of the collapse, contractor was performing structural modifications to the tower.

September 2018: Investigation of the Failures of Three Hammerhead Cranes on September 10, 2017, in Miami and Fort Lauderdale in the Wake of Hurricane Irma.

Three hammerhead tower cranes collapsed within hours of each other; two in Miami and one in Ft. Lauderdale, Fla., during heavy winds in the wake of Hurricane Irma. The three cranes were the same model SK-315. There was another SK 315 model crane that did not collapse which was at a much lower height and was shielded by tall structures. There were Terex manufactured cranes other than SK 315 in the area which did not fail. The crane jibs detached from their turntables due to turbulent wind and the cranes failed.

June 2018: Investigation of the Trench Collapse at I-95 on February 4, 2018, in Miami, FL

To repair a damaged or misaligned buried drainage pipe, the employees were hand-digging a trench besides a newly installed concrete barrier, more than 130 feet long. The concrete barrier collapsed into the trench while the employees were digging the trench. Two employees in the trench were killed.

February 2018: Investigation of the September 27, 2017, Gin Pole Collapse at an Antenna Tower in Miami Gardens, Florida.

Three employees were engaged in installing a new antenna for a local TV station at the top of a 951-foot tall antenna tower constructed in 2009. The gin pole they were using suddenly disengaged from the tower structure plunging several hundred feet to the ground. The employees were tied to the gin pole and fell with it and were killed. The cause of the disengagement was the failure of attachment between the gin pole and the tower structure.

April 2017: Investigation of the October 19, 2016, Collapse of Two Scaffold Platforms during Climbing in Miami, Florida.

Two scaffolds, known as Doka Xclimb 60 loading platforms, collapsed and several pieces of debris from the platform fell to the ground from the 48th floor of a high-rise residential building under construction in downtown Miami. The contractor was hydraulically climbing two scaffolds together, from the 47th floor to 48th floor and both scaffolds failed.

February 2017: Investigation of the September 1, 2016, Formwork Table Collapse in West Palm Beach, Florida.

A formwork table being installed for pouring concrete for construction of a multistory residential building failed and collapsed. The crews were installing the formwork tables on the 15th level. One of the employees fell to the ground along with the failed formwork table and was killed.

January 2017: Investigation of the July 19, 2016 Crane Collapse during Pile Driving for New Tappan Zee Bridge over Hudson River, Rockland County, NY.

A Manitowoc MLC300 crawler crane engaged in driving piles with a vibratory hammer for the construction of the new Tappan Zee Bridge collapsed and fell over the existing Tappan Zee Bridge. The incident occurred on the Rockland County side. The 256 foot-long boom of the crane fell over the existing bridge (north and southbound lanes of Interstate I-87/I-287).

August 2016: April 15, 2016 Double Tee Collapse at the Miami-Dade College West Campus Parking Garage, Doral, FL.

Miami-Dade College (MDC) decided to demolish the parking garage involved in 2012 incident and to build a new structure. During the construction of the replacement garage, two precast double tee beams collapsed on the fourth level of the new parking garage.

July 2016: Investigation of the February 5, 2016 Crane Collapse at 40 Worth Street, New York, NY

A Liebherr crawler crane, approximately 570 ft. high, collapsed in lower Manhattan, killing one motorist. The crane operator was attempting to lay down the crane in high wind when the crane suddenly collapsed and overturned. The crane had a luffing jib, 371 ft. long and a 194 ft. long boom. There was no load on either the boom or the jib hooks.

February 2016: Investigation of the September 9, 2015 Collapse of Aircraft Hangar No. 14 at Newark International Airport, Newark, NJ

At Newark Liberty International Airport, aircraft hangar no. 14, undergoing demolition, unexpectedly collapsed. The building was largely used for storage and no airplanes were parked inside the hangar. The contractor made numerous cuts on columns contrary to the consultant’s instructions and these additional cuts compromised the stability of the structure.

August 2015: Investigation of the March 23, 2015 Mast Climbing Scaffold Collapse during Dismantling at Raleigh, NC

A 12-story steel framed building with concrete floor slabs was under construction and the exterior of the building was to be clad with glass curtain walls. The construction was almost complete on March 23, 2015 when during the disassembly, one of the mast climbing work platforms collapsed. The mast supporting the platform partially collapsed. At the time of the incident, there were four employees on the platform perched near the 9th floor. All four fell to the ground with the falling mast and platform. Three were killed and the fourth fell on the roof of a portable toilet, and suffered severe injuries.

May 2015: Investigation of the January 19, 2015 Collapse of Bridge onto Southbound Interstate I-75 During Demolition in Cincinnati, OH

A construction incident occurred on Monday, January 19, 2015 near downtown Cincinnati at approximately 10:30 p.m. when the center and east spans of a ramp bridge being demolished suddenly fell 15-20 feet onto southbound interstate I-75 south freeway, killing a foreman and injuring the excavator operator. At the time of the incident, concrete slab was being removed from the deck of the ramp as a part of the demolition of the Hopple Street Ramp Bridge. The demolition work began a day earlier but had to be stopped due to concerns about some steel girders lifting off their bearings. Work resumed after the remedial measures recommended by the engineers were carried out. Those measures proved inadequate, and the incident occurred.

April 2015: Investigation of the November 13 and 14, 2014 Collapses of Two Pedestrian Bridges under Construction at Wake Technical Community College Campus, Raleigh, NC

On November 13, 2014 at approximately 10:30 a.m., a pedestrian bridge under construction at the Wake Technical Community College at the Northern Wake Campus, Raleigh, North Carolina, suddenly collapsed killing a worker. Four employees were injured. At the time of the collapse, concrete was being poured on the metal deck to provide the walking surface. A few hours later, another similar bridge, also under construction, within a block of the first incident, collapsed at approximately 12:30 a.m. in the middle of the following night. No one was injured in the second incident. No construction activities were going on during the second incident. Both bridges were part of the expansion of the Northern Wake campus which was well underway.

March 2015: Investigation of the December 30, 2014 incident at Ford Kansas City Assembly Plant, Claycomo, MO

A fatal incident occurred on December 30, 2014 at approximately 8:30 a.m. at the Ford Kansas City Assembly Plant (KCAP) in Claycomo, MO. The incident happened when the welds on a bracket holding a safety pin supporting the weight of a carriage suddenly failed, causing the carriage to slip off the pin and fall, pinning an employee who was working below the carriage.

October 2014: Investigation of the May 4, 2014 incident at the Ringling Bros. and Barnum and Bailey performance in Providence, RI

During the "Hair Hang Act" at the Ringling Bros. and Barnum & Bailey Circus show in Providence, RI, eight performers were suspended from their hair with their bodies free to dance in a choreographed acrobatic manner. Suddenly, during the act, the metal apparatus supporting the performers plummeted to the floor. Two of the performers sustained critical injuries. In total, there were injuries to nine employees. This incident occurred because the carabiner used to support the performers failed due to being improperly loaded.

August 2014: Investigation of the March 25, 2014 Failure of Gin Pole Rigging, and Collapse of Cellular Towers at Blaine, KS

On March 25, 2014, two communication towers owned by Union Pacific Railroad (Railroad) collapsed in Blaine, KS, killing two workers. The project consisted of dismantling an older communication tower with all its appurtenances (e.g., antennas, dishes, coaxial cables, etc.). The older tower was located next to a recently constructed tower. At the time of the incident, a gin pole was being raised on the older tower to lower a 10 ft. diameter dish when the rigging of the gin pole suddenly failed causing the 60 ft. tall gin pole to plummet down, resulting in the collapse of both the towers. One employee was situated approximately 20 ft. below the top on the older 250 ft. high tower and was engaged in disconnecting the 10 ft. diameter dish and another employee was on the same tower approximately 80 ft. from the top. One worker died at the scene and the other was pronounced dead at the hospital. There were two additional employees at the site who were not injured.

July 2014: Investigation of the February 1, 2014 Collapse of a Telecommunication Tower at the Summit Park Community in Clarksburg, WV

On February 1, 2014, at approximately 11:37 a.m., a 340 ft.-high guyed telecommunication tower (cell tower), suddenly collapsed during upgrading/construction activities. Four employees were working on the tower removing its diagonals. In the process, no temporary supports were installed. As a result of the tower's collapse, two employees were killed and two others were badly injured. The cell tower fell onto the guy wires of an adjacent smaller cell tower and caused it to collapse, killing a firefighter while he was rescuing the injured employees on the ground. The collapse of the smaller tower is not covered in this investigation.

July 2014: Structural Investigation of the January 20, 2014 Plant Collapse at International Nutrition Facility in Omaha, NE

A massive collapse occurred at a plant producing nutritional supplements for animal feed. There were nine bins each 8 ft. x 8 ft. x 27 ft. high, framed over the roof of the building. During filling of one of the bins with lime stone, the supporting structure collapsed and the entire plant had to be shut down. The facility was originally constructed around 1972. Two employees were killed and thirteen others were injured.

April 2014: Investigation of the November 2, 2013 collapse of concrete beams at Fort Lauderdale-Hollywood Airport runway project

On November 2, 2013, at approximately 1:30 p.m. an incident occurred at the construction site of the runway expansion project of Ft. Lauderdale-Hollywood International Airport when five precast concrete beams fell off their bearings, and an additional five beams slid off their bearings but remained over the concrete bents. The beams fell some 25 feet onto the railroad tracks owned by Florida East Coast Railways which operates trains multiple times a day hauling commodities across Florida. The beams were placed just a couple of days earlier and were to support the actual runway consisting of a post-tensioned concrete slab. One employee sustained minor injuries but the potential for multiple fatalities was very obvious.

March 2014: Investigation of the November 13, 2013 collapse of precast walls at a garage construction site, Ft. Lauderdale, FL

On November 13, 2013 an incident occurred at the construction site of a parking garage in Ft. Lauderdale, FL, where two precast walls weighing about 34 tons each suddenly fell. The walls were erected less than an hour before they fell. Two employees sustained injuries although this incident could have resulted in multiple fatalities. The parking garage was being constructed as a part of a larger project to construct new rental apartment buildings. The entire complex was called RD Flagler Village.

October 2013: Investigation of the May 23, 2013 Partial Collapse of a Prestressed Concrete Double Tee at Montgomery Mall in Bethesda, MD

A construction incident occurred on May 23, 2013, at approximately 1:45 p.m., when a prestressed concrete double tee partially collapsed while it was being jacked, killing one employee and injuring another. The double tee was 60 ft. long and 9 ft. wide, with a depth of 2 ft. 3 in. and a slab thickness of 4 inches. The weight of the double tee was approximately 42,800 pounds. The incident site was the Westlake Garage of the Westfield Montgomery Mall in Bethesda, MD.

October 2013: Investigation of the May 28, 2013 failure of gin pole rigging at a cell tower in Georgetown, MS

On May 28, 2013, a construction incident occurred at the site of Verizon Wireless cell tower in Georgetown, MS. The 300 ft. high cell tower was being equipped with a gin pole to replace the old antennas with new ones. While the gin pole, approximately 40 ft. tall was being raised, the rigging of the gin pole block suddenly failed, killing two workers located on the tower.

August 2013: Investigation of the March 31, 2013 Temporary Overhead Crane Collapse at Arkansas Nuclear One Power Plant in London/Russellville, AR

An incident occurred on March 31, 2013 inside the turbine building of Unit 1 at the Arkansas Nuclear One power plant in London/Russellville, AR. During the scheduled refueling outage of Unit 1, it was pre-planned to replace the turbine stator. While the old turbine stator was being removed and transported to the trailer deck, the temporary overhead crane supporting the old stator suddenly failed and collapsed, killing an employee. Eight other employees were injured. The turbine stator weighed over a million pounds.

July 2013: Investigation of the April 18, 2013 Partial Collapse of a Masonry Wall during construction of the Goodwill Retail Store in Hendersonville, TN

On April 18, 2013, partial collapse of a masonry wall occurred during construction of the Goodwill Retail Store in Hendersonville, TN. As a result of the wall collapse, two employees were killed and one was injured. The investigation and evaluation were based on the information provided by the Division of Occupational Safety and Health of the State of Tennessee. The project consisted of construction of a one-story Goodwill Retail Store, approximately 170 ft. wide x 180 ft. long.

March 2013: Investigation of the October 10, 2012 Parking Garage Collapse during Construction at Miami Dade College, Doral, FL

A portion of the parking garage under construction suddenly collapsed, trapping and killing four employees and injuring three others. The six-story garage was 305 ft. x 390 ft., and 62 ft. high and was being constructed with precast concrete structural members. The collapse occurred over an area of 122 ft. by 132 ft. The heavy fallen concrete pieces weighed approximately 3,300 tons.

February 2013: Investigation of the September 6, 2012 Partial Collapse of a Slab during Construction at Hyatt Place, Omaha, NE

On September 6, 2012 at approximately 5:00 a.m., a partial collapse of the second level slab occurred during construction of the 159-room, ten-story building, Hyatt Place Hotel in Omaha, NE. At the time of the collapse, the northwest section of the second level was being placed with fresh concrete over the formwork. Twenty-five employees were working with the wet concrete. Six of them on the formwork fell 10 to 18 feet below to the ground level. Three employees were injured.

December 2012: Investigation of the September 10, 2012 Partial Collapse of a Building under Construction at 227 Carlton Avenue in Brooklyn, NY

The building under construction consisted of five townhouses, each four stories high. The structure consisted of load-bearing masonry walls with cold-formed steel C-joists and metal deck at each floor. At the time of the incident, materials were being delivered to the 4th floor. The front 20 feet of the floor collapsed over the third floor pancaking the floors below. One worker killed, 1 injured.

July 2012: Investigation of the March 22, 2012 Partial Building Collapse during Demolition at 604-606 West 131st Street, New York, NY

The project consisted of demolition of a 1920 built two-story warehouse building as part of Columbia University's expansion. During demolition, the building partially collapsed in an unplanned manner. One employee was killed and two employees were injured. The building was being used as a warehouse and a commercial parking garage.

May 2012: Investigation of November 8, 2011 Partial Collapse of a Building Under Construction at 2929 Brighton 5th Street, Brooklyn, NY

The front bay of the five-story building under construction suddenly collapsed. At the time of the incident, concrete was being pumped to the third floor. The building was a hybrid construction of load-bearing light metal framing with interior steel rolled shaped beams and columns, and masonry walls at the core. One worker killed, 2 injured.

March 2012: Investigation Of The September 7, 2011 Collapse of a Mobile Crane at the National Cathedral Site in Northwest Washington, DC

A 500-ton Liebherr mobile crane collapsed amid thunderstorms and heavy rain while it was being lowered to the ground. The crane's telescopic boom was 152 ft. and the attached lattice jib was 276 ft. long. The crane had been delivering materials over the cathedral building after earthquake damage. The crane tipped, overturned and fell its full length. One worker injured.

January 2012: Investigation of the July 27, 2011 Systems-engineered Metal Building Collapse in San Marcos, TX

A systems-engineered metal building (pre-engineered building) collapsed during construction, killing one worker and injuring another. The project consisted of erecting four buildings, with length varying from 35 ft. to 300 ft. and width varying from 20 ft. to 150 ft. The building unit was intended to be a new manufacturing plant.

October 2011: Investigation of the April 5, 2011 Flow Equalization Basin Wall Collapse at Wastewater Treatment Plant in Gatlinburg, TN

The east wall of the 30 ft. high concrete equalization basin suddenly separated from the rest of the structure under the hydrostatic pressure, and fell over a one story control room structure killing two employees.

August 2011: Investigation of the February 14, 2011 Partial Collapse of a Parking Structure Under Construction in San Antonio, TX

A partially erected precast concrete frame of the 3,300 car parking garage suddenly collapsed. The structural design was hybrid: precast concrete columns and beams, and cast-in-place post-tensioned floors. The collapsed frame was approximately 65' long, 56' wide and 80' high weighing approximately 900 tons. Two workers were injured.

December 2009: Investigation of the June 10, 2009 Mast Climbing Platform Collapse in Austin, Texas

A mast climbing platform partially collapsed at a 21-story concrete framed condominium building under construction. The mast and one half of the platform remained intact. Immediately before the incident, the platform descended from the 13th floor and stopped at the 11th floor when one half of the platform suddenly separated from the main frame (motorized unit) and fell to the seventh floor. Three workers were killed.

June 2009: Investigation of the December 19, 2008 Collapse of Atlanta Botanical Garden Canopy Walkway during Construction in Atlanta, GA

A spirally shaped pedestrian walkway steel bridge approximately 575' long and 11' to 18' wide under construction collapsed. At the time of the incident, concrete was being poured over the bridge deck. The collapse was massive, involving over seventy percent of the bridge. At the time of the collapse, the entire bridge structural frame was being supported over fifteen temporary shoring towers. One worker killed, 18 injured.

January 2009: Investigation of the July 18, 2008 Fatal Collapse of a Deep South Crane at Lyondell Basell Houston Refinery in Pasadena, TX

The crane was assembled at the site with a 420' boom, 240' mast, 61' spar and 836,000 pounds of main counterweight attached to the spar. An additional 836,000 pounds of auxiliary counterweight was to be attached to its pendants suspended from the mast tip at 105' from the axis of the crane. With this configuration, the crane would have a million pound lifting capacity at a maximum boom radius of 160'. The incident occurred during the installation of the auxiliary counterweight. Four workers were killed and 6 injured.

September 2008: Investigation of the March 15, 2008 Fatal Tower Crane Collapse at 303 East 51st Street, New York, NY

A 250 ft. high tower crane in uptown Manhattan, NY collapsed when the polyester slings supporting the suspended collar failed. The collar was positioned around the just "jumped" tower sections and was to be laterally tied to the building under construction to provide lateral support to the crane mast. There were six fatalities and injuries to one person.

May 2008: Investigation of the December 6, 2007 Fatal Parking Garage Collapse at Berkman Plaza 2 in Jacksonville, FL

The incident occurred during the construction of a five-story poured-in-place concrete parking garage. The structural design consisted of cast-in-place one way post-tensioned slabs and post-tensioned beams. The columns were also cast in place. At the time of the incident concrete was being poured on the 6th level. There were no re-shores below the third level. One worker was killed, and 21 injured.

December 2007: Investigation of the June 14, 2007, Incident at U.S. Highway 90 across St. Louis Bay, Pass Christian, MS

The new bridge under construction on U.S. 90 to connect the towns of Bay St. Louis and Pass Christian was to replace a nearby old bridge destroyed by Katrina. The incident occurred when the steel forms of a bridge column suddenly collapsed and fell into the bay while the form was being filled with wet concrete. Nine workers fell with the column into the bay. Two workers were killed.

October 2007: Investigation of the July 13, 2007 Collapse of Roof Trusses in Township of Franklin, NJ

A new medical office building was under construction when the long span wood roof trusses collapsed. The workers erected the trusses a few hours before and were installing temporary and permanent bracings and purlins at the time of the incident. Shortly before the incident, three bundles of 2x6s to be used as purlins and braces were placed over the top chord of the center trusses. Two workers were seriously injured.

February 2007: Investigation of the August 22, 2006 Fatal Excavation Collapse at Red Hook, St. Thomas, U.S. Virgin Islands

The project, 40,000 square foot retail and office complex with two levels of parking, was in the first phase of construction, i.e., excavation and site stabilization, when the incident occurred. A steep excavated slope, more than 40 foot high suddenly collapsed. The collapsed earth deposits buried a nearby excavator and killed the operator inside the cab.

November 2006: Investigation of the June 3, 2006 Collapse of Grandview Triangle Bridge in Kansas City, MO

The project consisted of demolishing a steel bridge 850 ft. long and 27 ft. wide with twelve spans of varying lengths. The steel girders' depths varied from 48" to 114" and the bridge deck consisted of a 9" thick concrete composite slab. During demolition, two spans collapsed in an unplanned manner, killing one worker and injuring another.

August 2006: Investigation of the March 1, 2006 Collapse of Stripping Platform at San Marco Place, Jacksonville, FL

Two construction workers fell twenty stories to the ground and died when the stripping platform they were working on failed. The incident occurred during the construction of a 22-story condominium building. The platform was supported on structural framing resting on the 19th floor concrete slab and on the underside of the 20th floor slab. There were three other employees on the platform at the time of the failure, but they were able to hang onto the railing and the net, and were rescued.

February 2006: Investigation of the August 3, 2005 Collapse of Roof Trusses at Natatorio de, San Juan, PR

The project consisted of construction of a large, one-story concrete and steel structure for an indoor swimming and diving pool with bleachers. The roof trusses were curved and spanned 190 feet and weighed approximately 80,000 pounds. The incident involved the collapse of three long span steel roof trusses and several steel bar joists that fell approximately 50 feet to the ground. Two workers were killed, 2 injured.

December 2004: Investigation of the July 22, 2004 Collapse of a Building, Tranquility at Hobe Sound, Hobe Sound, FL

The project consisted of ten 3-story buildings to construct 82 townhouses. Tunnel forms were used by the construction team for casting concrete on the floors and in the walls. The incident occurred while concrete was being poured on the third floor of one building. A portion of the building collapsed killing two workers and injuring three others. The building was approximately 53 ft. wide and 150 ft. long.

April 2004: Investigation of October 30, 2003 Fatal Parking Garage Collapse at the Tropicana Casino Resort, Atlantic City, NJ

A parking garage, part of the Tropicana Casino and Resort expansion project collapsed during construction. The ten-story parking garage was designed as a cast in place concrete structure with precast floor filigree system. At the time of the incident, concrete was being cast on the 8th level. The collapse resulted in the failure of five levels of an exterior bay. Four workers were killed and 20 injured.

January 2004: Investigation of the September 4, 2003 Collapse of the 1000-foot High TV Antenna Tower in Huntsville, AL

The 1,000 ft. guyed tower was being modified to add a new HDTV antenna and additional equipment. Installation of horizontal braces and replacing the top 14 ft. with a new 6 ft. tower section were to be undertaken. The crew had positioned a track and a gin pole on one face of the tower as a means to hoist the new antenna. The load line was attached to a block on the tower some thirty feet above the base. As the load line was tensioned, the tower collapsed killing three employees.

December 2003: Investigation of the July 23, 2003 Collapse of Custom Cantilever Finishing Platform in Panama City, FL

Four employees were placing grout bags and other materials on the cantilever section of the scaffold at the Hathaway Bridge construction site in Panama City, FL. As the grout bags were placed on the cantilever section, the scaffold suddenly failed, causing the employees to fall into the water. One worker was killed, 3 injured.

March 2003: Investigation of the September 24, 2002 Collapse of the 1965-foot High KDUH-TV Antenna Tower in Hemingford, NE

The 1965-foot high -KDUH-TV antenna tower was under contract to replace certain tower diagonals and struts to support a new high-definition TV antenna and other equipment. The tower consisted of 63 sections, each 30-foot high. The crew was replacing existing diagonals with new diagonals when the tower collapsed. Three workers were killed.

February 2003: Investigation of the October 24, 2001 Fatal Collapse of Two Scaffold Towers at 215 Park Avenue South in New York, NY

Two 142 ft. high scaffold towers collapsed, killing five workers and injuring 10 others. The towers were erected to provide a working platform for the facade renovation of a 1914 era 20-story steel framed masonry building. The face bricks and steel window lintels had already been removed from the 6th to the 14th floors and the cement plastering work was being done. At the time of the incident, two workers were manually hoisting a cement bag to the top of the scaffold tower.

December 2002: Investigation of the August 1, 2002 Collapse of Roadside Billboard During Erection in Snellville, GA

The project consisted of fabrication and erection of structural steel framing consisting of round steel pipes to support two billboard signs, on the two opposite faces, each weighing approximately 5,400 pounds. The workers engaged in electrical and bill board installation were finishing the newly erected sign. The billboard structural framing suddenly collapsed killing all three workers and crushing the cars parked below.

September 2002: Investigation of the August 5, 2002 Collapse of Tilt-Up Precast Concrete Wall Panels in Greensboro, NC

A tilt-up concrete wall 23' high and 20' wide, weighing 40,000 pounds, suddenly collapsed crushing three workers. The structure comprised of steel framing with steel columns, steel joist girders, joists and tilt-up wall panels on the perimeter.

December 2001: Investigation of the June 20, 2001 Partial Collapse of the Mast Climbing Platform at Cambridge, MA

The project consisted of construction of a six-story parking garage. The 55-foot long mast climbing platform consisted of 20 foot fixed platform plus extensions on either side supported in the center by a single mast. Three sections, each 5-foot long were installed on one side, and four sections were installed on the other side. The side, which had four sections collapsed. 3 workers were injured.

May 2000: Investigation of the December 16, 1999 Fatal Collapse of a Reinforcing Steel Cage at the Pier WB-12 of I-895 Bridge in Richmond, Virginia

A 44 ft. tall reinforcing steel cage weighing 80 tons fell over and killed one of the two workers working near the top of the cage. The deceased worker was caught between the collapsing reinforcing cage and the concrete footing surface. At the time of the incident, the two workers were installing horizontal ties. The wind at the time of the incident was about 25 mph.

April 1998: Investigation of the October 23, 1997 Collapse of the 1889-foot High TV Antenna Tower in Raymond, MS

The 1889-foot high antenna tower consisting of 64 sections, each 30 feet high, was being rehabilitated by replacing selected horizontal and diagonal members and guy wires. The workers were 1480' above the base replacing existing diagonal members when the tower collapsed. Three workers were killed.

January 1998: Investigation of the July 31, 1997 Collapse of the Parking Garage Steel Framing at the Portland International Airport, Portland, Oregon

Construction was underway at the Portland International Airport in Portland, Oregon to add four additional levels of parking to transform the existing two-story precast concrete parking garage into a seven level parking structure. Two partially completed bays of structural steel, most of which were erected the same day, collapsed killing three ironworkers.

March 1997: Investigation of the October 12, 1996 Collapse of a 1500-Feet High Antenna Tower in Cedar Hill, TX

A 1462 feet high antenna tower, collapsed while "jumping" a gin pole with a track near the top of the tower to replace an existing antenna. The workers fell to the ground with the falling sections of the tower. Three workers were killed.

June 1996: Structural Collapse at the Olympic Swimming Venue, Atlanta, Georgia. March 18, 1996

A steel structure under construction 176 ft. x 312 ft. and 130 ft. high collapsed at the construction site for the Olympic Aquatic Center in Atlanta, Georgia. The structure, was an addition to the existing pool structure. Just prior to the collapse, the steel erection crew had erected a steel frame and a pair of steel joists spanning 176 ft. from an existing structure to the erected steel frame. The failure occurred within 15 to 30 minutes after the crane was released from the paired joists. The incident did not result in any injuries.

June 1995: Collapse of a Mast Climbing Work Platform (Scaffold) in Miami, FL. March 4, 1995

The building project under construction was a 31-story condominium complex. Five employees were applying stucco to the fascia walls when the platform of a mast climbing work platform (scaffold) collapsed. Three employees were on a modified cantilever deck section, which was connected to platform extensions attached to the main platform. The cantilever deck failed and as a result, the three employees fell about 75 feet where they were fatally injured. The other two employees working on the platform, were able to grab and hold on to the structure, and sustained only minor injuries.

October 1994: Investigation of the June 6, 1994 Collapse of a Radio Tower in Selma, Alabama

A 350 ft. high guyed radio transmission tower collapsed during the final phase of its construction. Three FM antennas were already hoisted and fastened to the top sections of the tower. On the day of the incident, two workers positioned near the top section of the tower were beginning to lower the gin pole from the top section of the tower to the ground. The gin pole suddenly dropped and struck the coaxial cable, followed by the collapse of the tower. Both workers, who were tied to the collapsing tower, fell to the ground, resulted in the death of one worker and serious injuries to the other. The tower structure consisted of 25 pre-fabricated steel sections, each 10 ft. or 20 ft. in height.

December 1992: Investigation of July 20, 1992 Offshore Drilling Accident, Massachusetts Bay, Massachusetts

A pile top drill unit and a 206 feet long pipe casing, 68-inch diameter suddenly dropped 25 feet into the soft ocean sediment bed as the crane of the jack-up barge was releasing a 80 ton bottom hole assembly onto the platform of the drill unit. The fall of the drill unit caused injuries to three employees working on the platform. One of them was fatal. The steel casing was horizontally held above sea level by the jack-up barge, which was supported on four legs, each 7.5 feet square in cross-section.

March 1992: Investigation of October 17, 1991 Roof Cable Structure Accident at Georgia Dome Construction Site, Atlanta, Georgia

A construction worker was killed and two workers were injured when their work platform, about 230 ft. above ground, was struck by a collapsing steel post, during the erection of the roof cable structure at the Georgia Dome in Atlanta, GA. The workers were in the process of hoisting the center truss in position to make the final connection of a diagonal cable to the bottom joint of the center truss. The construction workers were using hydraulic pumps to apply loads to the temporary jacking strands in order to make the permanent diagonal cable connection to the center truss.

May 1991: Investigation of November 19, 1990 Excavation Collapse at 14th and H Streets, N.W. Washington, D.C.

The structural steel support system of an open excavation, 150 ft. x 208 ft. by 47 ft. deep collapsed causing a cave-in of several thousand cubic yards of soil. The excavation was done for the construction of a 12-story office building with four levels of underground parking. The collapse caused the internal support system to slide and fall into the open excavation. At the time of the incident, construction had stopped for the day and therefore did not cause any death or injury, though it had significant potential for casualties.

December 1990: Investigation of August 14, 1990 Collapse of Precast Concrete Beams at Airside Building, Midfield Terminal Project, Greater Pittsburgh International Airport, Allegheny County, Pennsylvania

The building under construction, the Airside Building, consisted of precast concrete beams, columns and precast prestressed hollow core concrete planks. During the erection and placement of hollow core precast planks at the roof level, several precast concrete beams, column, and hollow core planks at the roof and concourse levels collapsed. One construction worker, on the concourse level, died due to the falling debris of the collapsed beams and planks. Another construction worker was seriously injured.

May 1990: Investigation of a Tower Crane Collapse in San Francisco, California November 28, 1989

A tower crane collapsed in the center of the financial district in San Francisco, California. Four construction workers engaged in the climbing operation of the crane and one person on the street below the crane were killed. The SN 355 model crane, a climbing, luffing boom tower crane had a maximum reach of 192 feet and a maximum lift capacity of 17,000 pounds with two wire ropes. The height of the crane on the day of collapse was 298 feet and consisted of 15 identical sections added at different stages. On the day of the incident, climbing process was underway to add another tower section.

Only selected reports are posted on this webpage. For assistance with any of the reports, figures or illustrations, please contact the Directorate of Construction at (202) 693-2020.

• OSHA finds that structural engineers must specify the order and manner of replacing existing diagonals and strut members of cellular towers. Onsite judgement by workers engaged in retrofit of towers has often proven to be disastrous. (October 2018)
• OSHA finds that the contractors and engineers should consider turbulent winds causing uplift and vortex in areas exposed to tropical storms and hurricane. OSHA recommends analysis based on Computational Fluid Dynamics (CFD) calculations. (September 2018)
• OSHA finds that the contractor not laying the boom and jib in the face of impending wind in accord with the crane manufacturer's instruction caused the collapse of the crane. (July 2016)
• OSHA finds that contractors must exhibit abundance of caution and supervision during dismantling of mast climbing platforms, not to overload the platforms causing failure of the mast. (August 2015)
• U.S. Department of Labor Announces Initiative to Increase Awareness Of Trenching and Excavation Hazards and Solutions , OSHA News Release (November 28, 2018)
• U.S. Department of Labor Cites Five Contractors for Safety Violations Following Florida Pedestrian Bridge Collapse , OSHA News Release (September 18, 2018)
• U.S. Department of Labor Cites Pennsylvania Crane Manufacturer for Exposing Employees to Safety Hazards after Fatal Crane Collapse , DOL News Release (August 6, 2018)
• U.S. Department of Labor Cites Communication Tower Contractor Following Three Fatalities at Miami Work Site , OSHA News Release (March 27, 2018)
• OSHA finds that overloading led to Providence, Rhode Island, circus fall Ringling Bros. and Barnum & Bailey Circus cited for serious safety violation . OSHA Regional News Release, (November 4, 2014).
• US Labor Department and Federal Communications Commission announce working group to prevent fatalities in telecommunications industry . OSHA News Release, (October 14, 2014).
• Structural Collapses During Construction - Lessons Learned, (1990-2008) (PDF). STRUCTURE magazine. OSHA investigated 96 structural collapses during construction involving fatalities and injuries from 1990 to 2008. Construction errors contributed to 80% of the structural collapses while the remaining 20% of the incidents are attributed to structural design flaws. (December 2010).

Learn how you can use AI to improve your compliance data management in our webinar with KonaAI. Register here to join us April 30th!

• Resource Center

Investigation Report Example: How to Write an Investigative Report

• What is the Importance of an Investigative Report?
• How to Write an Investigative Report: "Musts"
• How CaseIQ Can Help

Preliminary Case Information

Here’s how to write an investigation report that is clear, complete, and compliant.

Do you dread the end of an investigation because you hate writing investigative reports? You’re not alone.

However, because it’s an important showcase of the investigation, you can’t cut corners on this critical investigation step. Your investigation report reflects on you and your investigation, so make sure it’s as clear, comprehensive, accurate, and polished.

How do you write an investigation report? What are the parts of an investigation report? What's an investigation report example? In this guide, you’ll learn how to make your workplace incident reports effective and efficient.

How mature are your workplace investigations?

An investigations maturity model can reveal your investigations program's strong points and areas for improvement. Learn how to evaluate your program in our upcoming fireside chat with investigations expert Meric Bloch.

An investigation report can:

• Spark some sort of action based on the findings it presents
• Record of the steps of the investigation
• Provide information for legal actions
• Provide valuable data to inform control and preventive measures

In short, your report documents what happened during the investigation and suggests what to do next.

In addition, the process of writing an investigation report can help you approach the investigation in a new way. You might think of more questions to ask the parties involved or understand an aspect of the incident that was unclear.

How to Write an Investigative Report: “Musts”

Before you begin, it’s important to understand the three critical tasks of a workplace investigative report.

• It must be organized in a such way that anybody internally or externally can understand it without having to reference other materials. That means it should have little to no jargon or specialized language and be a stand-alone summary of your investigation from start to finish.
• It must document the investigative findings objectively and accurately and provide decision makers with enough information to determine whether they should take further action.  With just one read-through, stakeholders should be able to understand what happened and how to handle it.
• It must indicate whether the allegations were substantiated, unsubstantiated, or whether there’s something missing that is needed to reach a conclusion. Use the evidence you’ve gathered to back up your analysis.

You might be wondering, “What are the contents of an investigation report?” Now that you know what your report should accomplish, we’ll move on to the sections it should include.

Want to streamline the report-writing process?

Download our free investigation report template to ensure you have consistent, compliant, and complete reports for every case.

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Investigation Report Format: What to Include in Your Workplace Incident Report

Executive summary, incident summary, allegation subject, investigation details & notes, investigation interviews, conclusion & recommendations, final edits, how case iq can help.

The executive summary should be a concise overview of the investigation from beginning to end. It should not contain any information that is not already in the investigation report.

This may be the most important component of the investigation report because many readers won’t need to go beyond this section. High-level stakeholders get an overall picture of the allegations, investigation, and outcome without having to pore over the details.

To make this section easy to read, write in an active voice. For example: “I interviewed Carrie Smith,” not “Carrie Smith was interviewed.”

Example:   On February 23 rd , 2023, the Human Resources Manager received a written complaint of sexual harassment submitted by Carrie Smith, the stockroom manager. Smith claimed that on February 22 nd , 2023, her supervisor, Mark Robinson, pushed her against the wall in the boardroom and groped her breasts. Smith also alleged that Robinson on another occasion told her she was “too pretty” to be working in the stockroom and that he could arrange for a promotion for her. 

On February 24th, the Human Resources Manager assigned the case to me.

On February 25th, I interviewed Carrie Smith and two witnesses to the alleged February 22 nd  incident, John Jones and Pamela Miller. Jones and Miller did not corroborate the groping allegation but said they saw Smith running out of the boardroom in tears. Miller also reported hearing Robinson tell another employee, Sara Brown, that she had “a great rack”. 

On February 26 th , I interviewed Mark Robinson. He denied the groping incident and said he was “just joking around” with her in the boardroom but did not actually touch her and that Smith was too sensitive. He admitted to telling Smith she was too pretty to work in the stockroom, but contends that it was meant as a compliment.

Based on the interviews with the complainant and the alleged offender, I find that the complainant’s allegation of sexual harassment is substantiated.

It is my recommendation that the company provide the respondent with a written account of the findings of the investigation and a reminder of the company’s expectations for employee behavior. I also recommend that the respondent receive sexual harassment training and be advised that repeated harassing behavior may result in further discipline up to and including termination.

This section outlines the preliminary case information in a concise format, with only the most important details. It can go either before or after the executive summary.

• Your name and investigator identification number, if you have one
• Case number
• Date the case was assigned to you
• The date the report was reviewed
• How the report was received (e.g. hotline, email to HR manager, verbal report to supervisor)
• Name of the reporter/complainant

If the reporter is an employee, record their:

• Email address
• Work telephone number
• Employment level/position
• Employee identification number
• Department identification number

If the source  is not an employee, only record their:

• Personal telephone number

In either case, note the date that the report was submitted, as well as the date(s) of the alleged incident(s).

The purpose of this section is to answer the who, what, where, and when about the incident.

• What type of case is it? For example, is the case alleging harassment, discrimination, fraud, or other workplace misconduct?
• Specify the case type further.  For example, is it  sexual  harassment,  gender  discrimination,  accounts payable  fraud, etc.
• Who is the alleged victim?  For example, is it the reporter, another employee, a customer, or the whole company?
• If the alleged victim is an employee, identify the person’s supervisor.
• Were any other people involved besides the subject and the alleged victim?
• Where did the incident(s) take place?
• When did the incident(s) occur?
• Capture details of the allegation.  Example : Stacey Smith alleges that John Jones, an accounts payables clerk, has been funneling payments to a dummy supplier that he has set up in the company’s procurement system. Stacey says that she noticed a discrepancy when one of the suppliers she deals with questioned a payment and she had to ask an accounts payable clerk, Tom Tierney, to pull the file for her. When Tom accidentally brought Stacey the wrong file, she saw that monthly payments were being made to a supplier she had never heard of, and that the address of the supplier was John Jones’s address. Stacey knows John’s address because her sister is John’s next-door neighbor.

Describe the allegation or complaint in simple, clear language. Avoid using jargon, acronyms, or technical terms that the average reader outside the company may not understand.

In this section, note details about the alleged bad actor. Some of this information might be included in the initial report/complaint, but others you might have to dig for, especially if the subject isn’t an employee of the organization.

For every subject, include their:

• Email (work contact if they’re an employee, personal if not)
• Telephone number (see above)

If the subject of the allegation is an employee, also include their:

• Employment status (e.g. full-time, part-time, intern, contractor, etc.)
• Business location

Begin outlining the investigation details by defining the scope. It’s important to keep the scope of the investigation focused narrowly on the allegation and avoid drawing separate but related investigations into the report.

Example:   The investigation will focus on the anonymous tip received through the whistleblower hotline. The objective of the investigation is to determine whether the allegation reported via the hotline is true or false.

Next, record a description of each action taken during the investigation. This becomes a diary of your investigation, showing everything that was done during the investigation, who did it, and when.

For each action, outline:

• Type of action (e.g. initial review, meeting, contacting parties, conducting an interview, following up)
• Person responsible for the action
• Date when the action was completed
• Brief description of the action (i.e. who you met with, where, and for how long)

Be thorough and detailed, because this section of your report can be an invaluable resource if you are ever challenged on any details of your investigation.

Write a summary of each interview. These should be brief outlines listed separately for each interview.

Include the following information:

• Who conducted the interview
• Who was interviewed
• Where the interview took place
• Date of the interview

Include a list of people who refused to be interviewed or could not be interviewed and why.

Write a Report for Each Interview

This is an expanded version of the summaries documented above. Even though some of the information is repeated, be sure to include it so that you can use the summaries and reports separately as standalone documentation of the interviews conducted.

For each interview, document:

• Location of the interview
• Summary of the substance of the interview, based on your interview notes or recording.

Example:   I asked Jane Jameson to describe the events of July 13 th , 2016. She said: “After work, Peter approached me as I was leaving the building and asked me if I would like to work on his team. When I said that I was happy working with my current team, he told me that my team had too many women on it and that ‘all those hormones are causing problems’ so I should think about moving to a ‘sane’ team.”

I asked her how she reacted to that. She said: I told him that I found that offensive and he said that I needed to stop being so sensitive. I just walked away.”

I asked Jane to describe the events of the next day. She said: “The next day he came to my desk and asked me if I had given any thought to moving to his team. I repeated that I was happy where I was. At that point he started massaging my shoulders and said that moving to his team would have its ‘perks’. I asked him to stop twice and he wouldn’t. Sally walked over and told him to get lost and ‘leave Jane alone’ and he left.”

I thanked Jane for her cooperation and concluded the interview.

Assess Credibility

Aside from collecting the evidence, it is also an investigator’s job to analyze the evidence and reach a conclusion. Include a credibility assessment for each interview subject in the interview report. Describe your reasons for determining that the interviewee is or isn’t a credible source of information.

This involves assessing the credibility of the witness. The EEOC has published guidelines that recommend examining the following factors:

• Plausibility – Is the testimony believable and does it make sense?
• Demeanor – Did the person seem to be telling the truth?
• Motive to falsify – Does the person have a reason to lie?
• Corroboration – Is there testimony or evidence that corroborates the witness’s account?
• Past record – Does the subject have a history of similar behavior?

Example:   I consider Jane to be a credible interviewee based on the corroboration of her story with Sally and also because she has nothing to gain by reporting these incidents. She has no prior relationship with Peter and seemed genuinely upset by his behavior.

A well-written report is the only way to prove that an investigation was carried out thoroughly.

Download this free cheat sheet to learn best practices of writing investigation reports.

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In this section, describe all the evidence obtained. This could include:

• Video or audio footage
• Email or messaging (e.g. Slack, Teams, etc.) records
• Employee security access records
• Computer or other device login records
• Documents or papers
• Physical objects (e.g. photos, posters, broken objects, etc.)

Number each piece of evidence for easy reference in your chain of evidence document.

As you gather and analyze evidence , it’s critically important to include and fully consider everything you find. Ignoring evidence that doesn’t support your conclusion will undermine your investigation and your credibility as an investigator. If you aren’t weighing some pieces as heavily as others, make sure you have a good explanation as to why.

In the final section of your report, detail your findings and conclusion. In other words, answer the questions that your investigation set out to answer.

This is where your analysis comes into play. However, be sure to only address the issue(s) being examined only, and don’t include any information that is not supported by fact. Otherwise, you could be accused of bias or speculation if the subject challenges your findings.

Investigation Findings Example:   My findings indicate that, based on the evidence, Bill’s allegation that Jim blocked him from the promotion is true. Jim’s behavior towards Bill is consistent with the definition of racial discrimination. The company’s code of conduct forbids discrimination; therefore, Jim’s behavior constitutes employee misconduct.

It’s important for your conclusion to be defensible, based on the evidence you have presented in your investigation report. Reference reliable evidence that is relevant to the case. Finally, explain that you’ve considered all the evidence, not just pieces that support your conclusion.

In some cases, you might have been asked to provide recommendations, too. Depending on your conclusion, you may recommend that the company:

• Does nothing
• Provides counseling or training
• Disciplines the employee(s)
• Transfers the employee(s)
• Terminates or demotes the employee(s)

Example: It is my recommendation that the company provide the respondent (Jim) with a written account of the findings of the investigation and a reminder of the company’s expectations for employee behavior. I also recommend that the respondent (Jim) receive anti-discrimination training and be advised that repeated discriminatory behavior may result in further discipline up to and including termination.

Grammatical errors or missed words can take even the best investigation report from professional to sloppy. That’s why checking your work before submitting the report is perhaps the most important step of them all.

Keep in mind that your investigative report may be seen by your supervisors, directors, and even C-level executives in your company, as well as attorneys and judges if the case goes to court.

If spelling, grammar, and punctuation aren’t your strong suit, enlist the services of a writer-friend or colleague to proofread your report. Or, if you’re a lone wolf kind of worker, upgrade your skills with a writing course or a read-through of books like  The Elements of Style by Strunk and White. At the very least, remember to run a spell check before you pass on any document to others.

Finally, do a quick scan to make sure you’ve included all the necessary sections and that case details are consistent.

Want more report-writing tips?

Watch our free webinar to get advice on what to include (and not include), proper language and tone, formatting tips, and more on how to effectively make an investigation report.

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RELATED: 3 Investigation Report Writing Mistakes You’re Still Making

Frequently Asked Questions

How do i write an investigation report.

To write an investigation report, you should ensure it's clear, comprehensive, accurate, and organized, documenting findings objectively and providing decision-makers with enough information to determine further action.

What are the basic parts of an investigation report?

The basic parts of an investigation report include an executive summary, preliminary case information, incident summary, allegation subject details, investigation details and notes, investigation interviews, evidence documentation, conclusion and recommendations, and final edits.

What is the purpose of an investigation report?

The purpose of an investigation report is to document the steps and findings of an investigation, providing a clear record of what occurred, suggesting actions to be taken, and potentially serving as valuable data for legal actions or informing control and preventive measures.

If you’re still managing cases with spreadsheets or outdated systems, you’re putting your organization at risk.

With all your investigation information stored in one place, you can create comprehensive, compliant investigation reports with a single click. Case IQ’s powerful case management software pulls all the information from the case file automatically, so you can close cases faster.

Learn more about how Case IQ can reduce resolution time and improve your organization’s investigations here.

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Case Study: Incident Response and Forensics Analysis

We are experts in Incident Response and Forensics Analysis. When electronic invasion occurs we:

• Evaluate the type of attack to accurately identify its origin,
• Contain the attack so that it cannot affect other systems, and
• Provide step-by-step analysis and incident documentation.

In addition, we have the following capabilities to perform forensics analysis services more efficiently for our clients:

• For data residing at the Security Operation Center (SOC), we provide forensics analysis services remotely such as forensics analysis via remote access sessions,
• We respond to security event and perform forensics analysis at the client site, and
• Service Level Agreement (SLA) for incident response time is within 2 hours for phone support and within 8 hours for onsite analysis.

We develop client-specific prevention programs to deter future attacks and ensure the integrity of our client’s sensitive information. We perform incident response and forensics analysis on both network and web applications. Our growing client list includes law firms, financial institutions, and healthcare companies.

Incident Response and Forensics Analysis Methodology

Our staff holds professional certifications in CISSP, CSSLP, CISA, CRISC, CIPP, and CIPP/G, and are well versed with the regulatory compliance requirements of HIPAA, GLBA, FFIEC, SOX, PCI, FISMA, DIACAP, and other Federal and State privacy regulation requirements. Our methodology for computer incident handling / forensics analysis is listed below, and all steps are documented in detail by the forensics expert assigned to the case.

1. Identification Phase:

• Verify the authority of the investigating officer.
• Consult with the investigating officer on the scene to understand the situation and determine the necessary equipment to bring to the scene.
• Identify the incident’s sequence of events and respective dates/times.
• Identify actions that were performed to resolve the incident
• Identify who has been contacted (i.e. law enforcement, third-parties, internal corporate officers)
• Identify evidence that has been preserved
• Identify available logs(web server, database server, firewall, intrusion detection/prevention system (IDS/IPS),and router logs)
• Identify and understand the details of any third party complaints.

2. Seizing Evidence:

a. Consult with the Investigating Officer on the scene for

• any special instructions
• situational awareness (what happened, who is involved, other additional information and circumstances)
• contact information
• the goal of the investigation / examination
• estimate duration of the forensics analysis
• establish deadline for the analysis report

b. Assist client with contacting and relaying incident details to client’s legal counsel when appropriate. c. Review legal authorization to seize evidence, and obtain additional authorization when necessary for the execution of seizure when evidence is outside the scope of the search. d. When it is impractical to remove the evidence from the scene, the evidence items are copied or imaged according to the procedures within the client organization.

Capture forensic image(s) using forensics hardware/software capable of capturing a “bit stream” image of the original media.

• Utilize methods of acquiring evidence that are forensically sound and verifiable.
• Ensure the integrity of the digital evidence to be submitted for examination is properly preserved.
• Archive forensic image(s) to media and maintain it consistently with departmental policy and applicable laws

e. Gather the network and data flow diagrams where available f. Gather all available logs (web server, database server, firewall, intrusion detection system (IDS), and router logs). g. Remove all suspects, witnesses, and by-standers from the proximity of digital evidence to preclude their access to potential evidence. h. Solicit information from potential suspects, witnesses, LAN administrators, etc. to ascertain knowledge of the system to be seized (e.g., password(s), operating system(s), screen name, email address). i. Search the scene systematically and thoroughly for evidence.

3. Forensics Analysis/Examination:

a. Review documentation provided by the client to determine the processes and legal authorization required to complete the examination. b. Understand the client’s need:

• Urgency and priority of the client’s need for information
• Additional types of forensic examination that may be required to be carried out on the evidentiary item.
• Identify the items that offer the best choice of target data in terms of evidentiary value

c. Agree upon examination strategy. d. Conduct examinations on forensic copies or via forensic image files and not on the original evidence media whenever possible. e. Conduct examinations of the media logically and systematically – and consistently with the client organization’s Standard Operating Procedures (SOPs). f. Reconstruct the “crime scene” for investigation when possible. g. Correlate and analyze logs when available h. Identify exact exploitation and vulnerabilities related to the incident. i. If the incident is related to internet hacking, research related exploitation and incidents to identify if this is a targeted attack or an attack due to a virus in the wild.

4. Evidence Handling Documentation:

a. Obtain copy of legal authorization b. Establish chain of custody – document the following detail on evidence

• What is the evidence?
• How did you get it?
• When was it collected?
• Who has handled it?
• Why did that person handle it?
• Where has it traveled, and where was it ultimately stored?

c. Determine the initial count of evidence to be examined d. Assess the packaging and condition of the evidence upon receipt by the examiner e. Write a description of the evidence f. Document communications regarding the case

5. Analyze and Report:

a. Analyze all data gathered b. Complete and submit investigation report

Case Study 1: Users can not logon to domain, corporate network is inoperable…

• Client: Major International Law Firm
• Users could not log onto the network or Windows domain
• The entire corporate network was inoperable
• All email services went down
• The client is a large law firm with a prominent public profile.
• The breach was initially suspected to be a targeted attack.
• Multiple media sources had written accounts of a specific group’s sophisticated hacking capabilities.
• An Incident Response and Forensics Analysis Team was deployed to the client site within 4 hours.
• All available evidence was imaged and backed up.
• Logs were gathered from the internal/external web servers, firewall, routers, IDS/IPS, Windows event logs.
• Evidence files obtained from server hard drives were analyzed.
• All collected logs were correlated and analyzed.
• Services and processes on the effected computers were analyzed.
• Windows Server, Router and firewall configurations were analyzed.
• Every step of the investigation was documented in detail.
• The KLC team discovered a sophisticated botnet with command and control software installed.
• The botnet changed the security policies on the servers preventing authorized users from logging in.
• The botnet was a brand new form of malware, and no public information was available until 5 days later.
• The root cause of the vulnerability was determined by the KLC team to be due to a mis-configuration of the firewall.
• The KLC Team provided an analysis report and recommendation on root cause remediation.
• The KLC Team assisted the client with the root cause remediation process and restored the network and email operation.
• Based on the evaluation, The KLC team concluded this instance was not the result of a targeted attack.

Case Study 2: Evidence of hacking was discovered on a web server with HIPAA data…

• Client: Major Healthcare Company
• The web server had been compromised.
• The database and the web server were on the same physical server, and HIPAA regulated data was involved.
• The incident happened 4 months prior and over the course of a 5 day period, based on the initial findings of the new development firm.
• No logs were available other than the web server logs for those 5 days.
• The client needed to know the extent of the damage, and whether they were required to take legal measures such as provide breach notification(s) and report the breach(s) to the attorney general.
• Web server technology, development platform and programming language were gathered.
• Database server information and a backup copy of the database were provided.
• Limited web server logs were gathered.
• KLC researched the attacks perpetrated against the web application.
• KLC built a forensics analysis environment to analyze the web application and database.
• KLC analyzed the database to determine the origination and scope of the attack.
• KLC correlated the web server logs against the database activities.
• Based on the research of the web server technology and development platform, a malware was targeting these types of servers during the period of the incident.
• Several files were intentionally left behind by the hackers.
• The server was hacked more than once because multiple hackers (or hacking groups) left their files.
• The hackers appear to be of overseas origination as identified through the language of the files.
• Database activities were inconclusive due to the limited logs available; but since health information and social security numbers could easily have been retrieved, breach notification steps were recommended.
• KLC consultants worked with the client’s legal counsel to share information discovered.
• KLC team delivered a report with detailed database activity and web server log analysis.
• Recommendations were provided to remediate web server situations and data protection on the database.

Check out these FREE resources and tools from CISA (Cybersecurity Infrastructure and Services Agency) to assist with your Incident Response and Forensics Analysis needs

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Ship that caused bridge collapse had apparent electrical issues while still docked, AP source says

FBI agents were aboard the cargo ship Dali as a criminal investigation opens into the deadly collapse of Baltimore’s Francis Scott Key Bridge. Attorney L. Chris Stewart, representing some of the victims, said their deaths were preventable and said the families appreciated the federal investigation.

People are seen aboard the container ship Dali, Monday, April 15, 2024, in Baltimore. The FBI confirmed that agents were aboard the Dali conducting court-authorized law enforcement activity. (AP Photo/Julia Nikhinson)

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FBI agents get on board the cargo ship Dali on Monday, April 15, 2024 in Baltimore. The FBI is conducting a criminal investigation into the deadly collapse of the Francis Scott Key Bridge that is focused on the circumstances leading up to it and whether all federal laws were followed, according to someone familiar with the matter. (WJLA via AP)

The collapsed Francis Scott Key Bridge lays on top of the container ship Dali, Monday, April 15, 2024, in Baltimore. The FBI confirmed that agents were aboard the Dali conducting court-authorized law enforcement activity. (AP Photo/Julia Nikhinson)

FILE - The container ship Dali is stuck under part of the Francis Scott Key Bridge after the ship hit the bridge, March 26, 2024, in Baltimore, Md. The FBI is conducting a criminal investigation into the deadly collapse of Baltimore’s Francis Scott Key Bridge that is focused on the circumstances leading up to it and whether all federal laws were followed. The FBI says Monday, April 15 it was present conducting court authorized law enforcement activity. (AP Photo/Steve Helber, File)

FILE - This satellite image provided by Maxar shows the bow of the container ship Dali remains stuck underneath sections of the fallen Francis Scott Key Bridge, in Baltimore, April 8, 2024. The FBI is conducting a criminal investigation into the deadly collapse of Baltimore’s Francis Scott Key Bridge that is focused on the circumstances leading up to it and whether all federal laws were followed. The FBI says Monday, April 15 it was present conducting court authorized law enforcement activity. (Satellite image ©2024 Maxar Technologies via AP, file)

Salvage work continues on the collapsed Francis Scott Key Bridge, Monday, April 15, 2024, in Baltimore. The FBI confirmed that agents were aboard the Dali conducting court-authorized law enforcement activity. (AP Photo/Julia Nikhinson)

People work on a standing section of the collapsed Francis Scott Key Bridge, Monday, April 15, 2024, in Baltimore. The FBI confirmed that agents were aboard the Dali conducting court-authorized law enforcement activity. (AP Photo/Julia Nikhinson)

The collapsed Francis Scott Key Bridge lay on top of the container ship Dali, Monday, April 15, 2024, in Baltimore. The FBI confirmed that agents were aboard the Dali conducting court-authorized law enforcement activity. (AP Photo/Julia Nikhinson)

The U.S. Army Corps of Engineers debris removal vessel The Reynolds works near the collapsed Francis Scott Key Bridge, Monday, April 15, 2024, in Baltimore. The FBI confirmed that agents were aboard the Dali conducting court-authorized law enforcement activity. (AP Photo/Julia Nikhinson)

BALTIMORE (AP) — Hours before leaving port, the massive container ship that caused the deadly collapse of a Baltimore bridge experienced apparent electrical problems, a person with knowledge of the situation told The Associated Press on Monday, the same day FBI agents boarded the vessel amid a criminal investigation into the circumstances leading up to the catastrophe.

The Dali departed Baltimore’s port early on March 26 laden with cargo destined for Sri Lanka. It lost power before reaching open water and struck one of the supports for Francis Scott Key Bridge, causing the span to collapse into the Patapsco River and sending six members of a road repair crew plummeting to their deaths. Two of the victims are still unaccounted for.

Authorities announced Monday evening the recovery of a fourth body from a construction vehicle in the underwater wreckage. The person’s identity wasn’t released per their family’s request, officials said.

While the ship was docked in Baltimore, alarms went off on some of its refrigerated containers, indicating an inconsistent power supply, according to the person with knowledge of the situation who was not authorized to publicly comment and spoke to AP on condition of anonymity.

Officials with the National Transportation Safety Board have said their investigation will include an inquiry into whether the ship experienced power issues before starting its voyage.

Board Chair Jennifer Homendy said last week the investigation is focused on the ship’s electrical system generally. The ship experienced power issues moments before the crash, as is evident in videos that show its lights going out and coming back on.

Homendy said information gleaned from the vessel’s voyage data recorder is relatively basic, “so that information in the engine room will help us tremendously.”

The FBI is now conducting a criminal investigation into the bridge collapse that is focused on the circumstances leading up to it and whether all federal laws were followed, according to a different person familiar with the matter. The person wasn’t authorized to discuss details of the investigation publicly and spoke to the AP on the condition of anonymity.

FBI agents were aboard the cargo ship on Monday conducting court-authorized law enforcement activity, the agency said in a statement. It didn’t elaborate and said it wouldn’t comment further on the investigation, which was first reported by The Washington Post.

Meanwhile, Mayor Brandon Scott issued a statement Monday announcing a partnership with two law firms to “launch legal action to hold the wrongdoers responsible” and mitigate harm to the people of Baltimore. He said the city needs to act quickly to protect its own interests.

Scott said the city “will take decisive action to hold responsible all entities accountable for the Key Bridge tragedy,” including the owner, operator and manufacturer of the cargo ship Dali, which began its journey roughly a half-hour before losing power and veering off course.

The Dali is managed by Synergy Marine Group and owned by Grace Ocean Private Ltd., both of Singapore. Danish shipping giant Maersk chartered the Dali.

Synergy and Grace Ocean filed a court petition soon after the collapse seeking to limit their legal liability — a routine procedure for cases litigated under U.S. maritime law. Their joint filing seeks to cap the companies’ liability at roughly $43.6 million. It estimates that the vessel itself is valued at up to $90 million and was owed over $1.1 million in income from freight. The estimate also deducts two major expenses: at least $28 million in repair costs and at least $19.5 million in salvage costs.

“Due to the magnitude of the incident, there are various government agencies conducting investigations, in which we are fully participating,” Synergy spokesperson Darrell Wilson said in a statement Monday. “Out of respect for these investigations and any future legal proceedings, it would be inappropriate to comment further at this time.”

The companies filed their petition under a provision of an 1851 maritime law that allows them to seek to limit their liability to the value of the vessel’s remains after a casualty.

Attorneys for some of the victims and a worker who survived the collapse argued Monday that the companies that own and manage the ship are taking advantage of an “archaic law” in attempting to protect their assets.

“Imagine telling that to grieving families … while they’re planning a funeral, the owner of the boat is in court,” attorney L. Chris Stewart said during a news conference in Baltimore.

The road crew “absolutely had zero warning” in the moments before the collapse, Stewart said, even though a last-minute mayday call from the ship’s pilot allowed nearby police officers to stop traffic from trying to cross the span. Three of the workers’ bodies are still missing, as crews continue the dangerous work of removing massive chunks of steel from the river.

Julio Cervantes, who survived falling from the bridge, narrowly escaped drowning by rolling down his work vehicle’s window and fighting through the frigid water despite being unable to swim, attorneys said. He clung to debris until he was rescued.

“This was all preventable,” Stewart said. “That is why we were brought in to investigate and find out what has happened and give these families a voice.”

The investigations come amid concerns about the safety of thousands of U.S. bridges and days after more than two dozen river barges broke loose and struck a closed span in Pittsburgh.

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Dubai’s Extraordinary Flooding: Here’s What to Know

Images of a saturated desert metropolis startled the world, prompting talk of cloud seeding, climate change and designing cities for intensified weather.

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By Raymond Zhong

Scenes of flood-ravaged neighborhoods in one of the planet’s driest regions have stunned the world this week. Heavy rains in the United Arab Emirates and Oman submerged cars, clogged highways and killed at least 21 people. Flights out of Dubai’s airport, a major global hub, were severely disrupted.

The downpours weren’t a freak event — forecasters anticipated the storms several days out and issued warnings. But they were certainly unusual. Here’s what to know.

Heavy rain there is rare, but not unheard-of.

On average, the Arabian Peninsula receives a scant few inches of rain a year, although scientists have found that a sizable chunk of that precipitation falls in infrequent but severe bursts, not as periodic showers.

U.A.E. officials said the 24-hour rain total on Tuesday was the country’s largest since records there began in 1949 . But parts of the nation had experienced an earlier round of thunderstorms just last month.

Oman, with its coastline on the Arabian Sea, is also vulnerable to tropical cyclones. Past storms there have brought torrential rain, powerful winds and mudslides, causing extensive damage.

Global warming is projected to intensify downpours.

Stronger storms are a key consequence of human-caused global warming. As the atmosphere gets hotter, it can hold more moisture, which can eventually make its way down to the earth as rain or snow.

But that doesn’t mean rainfall patterns are changing in precisely the same way across every corner of the globe.

In their latest assessment of climate research , scientists convened by the United Nations found there wasn’t enough data to have firm conclusions about rainfall trends in the Arabian Peninsula and how climate change was affecting them. The researchers said, however, that if global warming were to be allowed to continue worsening in the coming decades, extreme downpours in the region would quite likely become more intense and more frequent.

The role of cloud seeding isn’t clear.

The U.A.E. has for decades worked to increase rainfall and boost water supplies by seeding clouds. Essentially, this involves shooting particles into clouds to encourage the moisture to gather into larger, heavier droplets, ones that are more likely to fall as rain or snow.

Cloud seeding and other rain-enhancement methods have been tried across the world, including in Australia, China, India, Israel, South Africa and the United States. Studies have found that these operations can, at best, affect precipitation modestly — enough to turn a downpour into a bigger downpour, but probably not a drizzle into a deluge.

Still, experts said pinning down how much seeding might have contributed to this week’s storms would require detailed study.

“In general, it is quite a challenge to assess the impact of seeding,” said Luca Delle Monache, a climate scientist at the Scripps Institution of Oceanography in La Jolla, Calif. Dr. Delle Monache has been leading efforts to use artificial intelligence to improve the U.A.E.’s rain-enhancement program.

An official with the U.A.E.’s National Center of Meteorology, Omar Al Yazeedi, told news outlets this week that the agency didn’t conduct any seeding during the latest storms. His statements didn’t make clear, however, whether that was also true in the hours or days before.

Mr. Al Yazeedi didn’t respond to emailed questions from The New York Times on Thursday, and Adel Kamal, a spokesman for the center, didn’t immediately have further comment.

Cities in dry places just aren’t designed for floods.

Wherever it happens, flooding isn’t just a matter of how much rain comes down. It’s also about what happens to all that water once it’s on the ground — most critically, in the places people live.

Cities in arid regions often aren’t designed to drain very effectively. In these areas, paved surfaces block rain from seeping into the earth below, forcing it into drainage systems that can easily become overwhelmed.

One recent study of Sharjah , the capital of the third-largest emirate in the U.A.E., found that the city’s rapid growth over the past half century had made it vulnerable to flooding at far lower levels of rain than before.

Omnia Al Desoukie contributed reporting.

Raymond Zhong reports on climate and environmental issues for The Times. More about Raymond Zhong

What caused Dubai floods? Experts cite climate change, not cloud seeding

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Reporting by Alexander Cornwell; editing by Maha El Dahan and Alexandra Hudson

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A ceremony to install a stalled presidential transition council in Haiti will take place Thursday morning on the outskirts of the capital Port-au-Prince, the office of outgoing Prime Minister Ariel Henry announced in a statement on Wednesday.

A coalition vessel successfully engaged one anti-ship ballistic missile (ASBM) launched from the Iranian-backed Houthi "terrorist-controlled areas" in Yemen over the Gulf of Aden, the U.S. Central Command (USCENTCOM) said on Thursday.