Major incident response and investigation
Stage 6: Investigation report
Step 6.1
For: Investigation Manager
Interim factual report
As soon as possible in the course of the investigation:
- present a report to the Executive and the chair of the MIPG on the full facts, as known, of the incident, and HSE’s early response and liaison arrangements
Performance standard
Present the report:
- at the earliest opportunity but within one month of the incident occurring
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Step 6.2
For: Investigation Team Leader
Draft investigation report
When the investigation is completed:
- prepare and submit a draft investigation report
and recommendations on the outcome of the investigation to the Investigation Board
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Step 6.3
For: Investigation Manager
Final report and recommendations
Finalise the investigation report and recommendations by:
- consulting MIIB on the draft report and recommendations
- consulting with the MIPG, through the chair, regarding the recommendations
Then:
- prepare the final investigation report for the Executive
- assign a unique identifying number to the report
- accurately describe and uniquely number any recommendations
Performance Standard
Present the report to the Executive:
- within three months of the completion of the investigation (excluding waiting for the completion of enforcement action)
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Step 6.4
For: Chair MIPG
Implementation of recommendations
Following presentation of the final report to the Executive:
- consult with Executive and MIPG how the recommendations for improvement identified in the interim
and final reports are to be implemented
- monitor implementation of the recommedations and report to Executive
Performance standard
Report progress on the implementation of recommendations to the Executive and the Board
- in the annual report
- or at a time determined by the Executive