Major Incident
Stage 6: Investigation report - Additional guidance
Investigation report
The report should describe the major incident response
arrangements applied and provide details of the event:
how it occurred, the duty holder(s) or other persons
involved, the consequences and how injuries, ill health
or damage arose.
The report should draw conclusions about immediate and
underlying causes of the incident, and where
relevant:
- demonstrate that all reasonable underlying
causes have been considered
- identify where controls for risk were
absent, inadequate or not properly implemented
- assess the effectiveness of the duty
holder's emergency procedures mitigating the
consequences
- examine the evidence concerning compliance
with legal and other relevant standards, draw
conclusions on where breaches have occurred and the
extent of the breaches and whether the evidence is
sufficient to support enforcement action
- examine if the duty holders performance at
other sites is relevant; for example any outstanding
enforcement action
- make proposals for prioritised action by
HSE and duty holders necessary to prevent recurrence
with timescales or detail actions already taken by the
duty holders and HSE
back to step 6.2
back to step 6.3
