Incident Investigation:

Recommendations,
Communication and Follow-Up
PARTICIPANT WORKBOOK
Incident Investigation:
Recommendations,
Communication and Follow-Up
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Copyright © 2010 Coastal Training Technologies Corp. A DuPont Company.

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All rights reserved. Printed in U.S.A.
 Incident Investigation: Recommendations, Communication and Follow-Up

CONTENTS
Review of Previous Module ..............................................................................2

Introduction .........................................................................................................3

Step 6: Recommend Corrective and Preventive Actions ..............................4

Step 7: Document and Communicate Findings .............................................6

Communication......................................................................................7

Elements of Communication................................................................9

Step 8: Follow Up ..............................................................................................10

Summary ............................................................................................................12

Review of Incident Investigation 8-Step Process .........................................13

Quiz .....................................................................................................................15

Answer Key .......................................................................................................18

© Coastal Training Technologies Corp. May not be reproduced in any form without written permission. 1
 Incident Investigation: Recommendations, Communication and Follow-Up

REVIEW OF PREVIOUS MODULE

In the previous module we covered:

• Step 4: Determine All Contributing Factors, and

• Step 5: Determine Systems to Be Strengthened of the 8-Step Incident
Investigation process.
• You learned the process of
uncovering root causes of
an incident and how to
categorize your data into
areas for further
exploration – Physical,
Human, and Operating
Systems.
• You also learned to keep
asking “why” until you
get to the key factors and
root causes of the incident.
• And finally, you learned
how to take the
investigation a step
further to determine
possible management
systems that may need to
be strengthened.

2 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
 Incident Investigation: Recommendations, Communication and Follow-Up

INTRODUCTION

In this module we’ll take you through the final three steps of the
incident investigation process - Step 6: Recommend Corrective and
Preventive Actions; Step 7: Document and Communicate Findings;
and Step 8: Follow Up.
This workbook will help you:
• Apply what you learn from identifying key factors and systems to be
strengthened and make the necessary changes to prevent a similar
incident from occurring again.
• Learn the importance of documenting and communicating problem
areas and solutions from the investigation to everyone on your team
and throughout the organization.
• Understand the importance of following up to be sure changes have
been implemented satisfactorily.
You’ve conducted the initial investigation, formed a team, determined
the facts, even delved further to identify the key factors that contributed
to the incident and pinpointed particular systems to strengthen within
your organization. Now it’s time to make recommendations for change.

Additional Notes:
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 Incident Investigation: Recommendations, Communication and Follow-Up

STEP 6: RECOMMEND CORRECTIVE AND

PREVENTIVE ACTIONS

In this step you will learn to recommend corrective and preventive actions.
• Identify at least one recommendation for each key factor.
In some cases, a broad recommendation may address multiple
key factors.
• Recommendations exist as corrective actions or preventive actions.
Corrective actions are intended to fix a hazard while preventive
actions prevent a hazard from occurring.
• There are three levels of a corrective action.
First, eliminate a hazard to insure the incident will never
happen again.
If this is not possible, the next best solution is to control
the hazard.
For a hazard that cannot be eliminated or controlled, make
rules, write procedures, and train people to protect themselves
appropriately.
• Consider first the actions that affect the hazards most likely to recur.
• Weigh the severity of hazards, the cost of hazards, and their impact on
the entire organization.
• Evaluate every suggestion for its value as a real solution to the problem.

Discussion Notes:
• What can be done to make sure people protect themselves
appropriately against a possible incident?
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 Incident Investigation: Recommendations, Communication and Follow-Up

• Give an example of how a hazard may be eliminated to prevent

recurrence of an incident.
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• Discuss ways to prevent spill and fall incidents in your facility.

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Additional Notes:
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 Incident Investigation: Recommendations, Communication and Follow-Up

STEP 7: DOCUMENT AND

COMMUNICATE FINDINGS

In this step you will learn the three parts to a recommendation.

• There are three parts to a recommendation.
First, make sure the description of the recommendation is clear.
Second, name the person and their position that will be
responsible for implementing the recommendation.
Third, identify a completion date – a time by which the change
should be implemented.
• Clearly define the results expected from a particular recommendation
and set priorities for each action, identifying which ones should be
completed before operations resume.
• Ensure recommendations are not ignored, but document and track
them outside of the investigation reporting.

6 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
 Incident Investigation: Recommendations, Communication and Follow-Up

Discussion Notes:
• Discuss why it’s important to not include any recommendations or
improvement suggestions that are not associated with the incident
facts or situation.
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COMMUNICATION
The importance of communicating your recommendations cannot be
emphasized enough.
• If people never see the recommendations and implement them, then
your goal of preventing the incident from recurring and protecting
people’s lives won’t be achieved.
• Communicating the information you have gathered, the lessons you
have learned, and your recommended solutions will go a long way
toward preventing incidents from happening again.
• When it comes to incident investigation, there are two levels of formal
communication: official investigation report and general report.
The first level is an official incident investigation report with a
limited distribution.
» This report identifies the details of what happened,
including who was involved; the root causes, which are
key factors and management system weaknesses; and
recommendations for corrective action that will address
the causes, including timing for completion and who is
responsible for taking action.

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 Incident Investigation: Recommendations, Communication and Follow-Up

» This report should be reviewed with all company and

contract employees who were involved in the incident.
» This report may also be shared with others in your
organization for learning purposes or with government
agencies who request it.
The second level is a widely distributed general report that
summarizes the circumstances, contributing factors, and
lessons learned.
» This document does not identify the people involved.
» The main purpose of this report is to increase
awareness, demonstrate commitment and concern for
people, and help others prevent similar incidents.
Discussion Notes:
• What types of information would be included in the communication
report in your facility?
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8 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
 Incident Investigation: Recommendations, Communication and Follow-Up

ELEMENTS OF COMMUNICATION
• In all communication about the incident, start with the WHAT.
Share what happened, its effect on people working in the
area, key factors, the recommended corrective action, and the
lessons learned.
• Next, identify the WHO. Who will receive this information?
Not everyone in the organization needs to know ALL
information; only those who will benefit from knowing
should be included.
• Decide HOW to communicate it most effectively.
Choose your method of communication depending on how
broad your intended audience is.
• You will quickly learn which methods of communication are most
effective at your site.

Discussion Notes:
• Describe different ways to communicate the incident with employees
at your facility.
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Additional Notes:
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© Coastal Training Technologies Corp. May not be reproduced in any form without written permission. 9
 Incident Investigation: Recommendations, Communication and Follow-Up

STEP 8: FOLLOW UP

In this final step of the incident investigation process you will learn how to
follow up on your recommendations for corrective or preventive actions.
• The goal of follow-up is to prevent a recurrence of the incident.
Ensure the recommendations receive prompt attention by
creating an action plan.
• Some recommendations may look good on paper, but are unrealistic or
difficult to put into place.
If a recommendation will not be followed or was not effective,
document why, provide an alternative and get management
approval to ensure thorough attention has been given to the
recommendation.
• Track the progress of your recommendations periodically.
• Prior to final closure of a recommendation, determine and verify that
the action is completed and fully addressed the original intent of the
recommendation.

10 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
 Incident Investigation: Recommendations, Communication and Follow-Up

Discussion Notes:
• Discuss some instances when recommendations may not be followed
and why.
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• Discuss how long you should track the progress of your

recommendations.
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Additional Notes:
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 Incident Investigation: Recommendations, Communication and Follow-Up

SUMMARY

In this module you’ve learned the final three steps of the incident
investigation process: the importance of recommending corrective and
preventive actions; documenting and communicating findings; and
following up to be sure your recommendations are implemented and
effective. You learned how to make clear and effective recommendations
and how to communicate expectations and priorities regarding
recommendations. And finally, you learned how to follow up to be sure
recommendations were implemented and effective and if not, what to do
about it.
Following these final steps of the incident investigation process completes
the cycle to help prevent similar incidents from happening again. More
importantly, taking these vital steps shows employees that you follow
through on what you say and that you care about them.

Additional Notes:
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12 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
 Incident Investigation: Recommendations, Communication and Follow-Up

REVIEW OF INCIDENT INVESTIGATION

8-STEP PROCESS

These eight steps are the backbone of an effective incident investigation and
will help make your investigation successful.

• STEP ONE – MAKE THE INITIAL RESPONSE AND COMPLETE

AN INITIAL REPORT.
The goal of initial response is to secure the safety of personnel
and the community.

• STEP TWO - FORM AN INVESTIGATION TEAM.

The people you involve on the team depend on the severity of
the incident and areas of expertise needed for the investigation.

• STEP THREE - DETERMINE THE FACTS.

The goal is to learn as much as possible about the facts of the
incident by looking at physical factors, human factors, and
operating systems.

• STEP FOUR - DETERMINE ALL CONTRIBUTING FACTORS.

A contributing factor is a circumstance that contributed to or
may reasonably be believed to have contributed to the
incident’s occurrence.

• STEP FIVE - DETERMINE SYSTEMS TO BE STRENGTHENED.

Often, there’s a problem with a system that contributed to the
chain of events leading to the incident.

© Coastal Training Technologies Corp. May not be reproduced in any form without written permission. 13
 Incident Investigation: Recommendations, Communication and Follow-Up

• STEP SIX - RECOMMEND CORRECTIVE AND PREVENTIVE

ACTIONS.
Recommendations should address all contributing factors.

• STEP SEVEN - DOCUMENT AND COMMUNICATE FINDINGS.

Draft and share a clear, concise report that communicates
what happened, what has been and is being done to correct
the situation and prevent it from happening again.

• STEP EIGHT - FOLLOW UP.

Make sure corrective actions are completed and effective.

No matter what, people are your priority and they are the reason for
incident investigations. Following these steps will help to reduce
incidents and make your workplace a safer and healthier place to work,
but it will demonstrate your care and concern for people’s lives.

Additional Notes:
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14 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
 Incident Investigation: Recommendations, Communication and Follow-Up

QUIZ

1. Recommendations exist as corrective actions or preventive actions

and corrective actions are intended to eliminate a hazard.
True False

2. A good practice in Step 6 of the investigative process is to identify

one recommendation even though there may be multiple key factors.
True False

3. For a hazard that cannot be controlled, make rules, write procedures

and train people to follow them.
True False

4. You should include in your final report any recommendation or

improvement suggestions even though they are not associated with
the incident.
True False

5. Prior to final closure of a recommendation, verify that the action is

completed and fully addressed the original intent of the
recommendation.
True False

6. If a recommendation will not be followed, document why, suggest

an alternative, and require management approval to ensure thorough
attention has been given to the recommendation.
True False

7. Everyone in the organization needs to know all the information

relating to an incident, so be sure it’s communicated.
True False

© Coastal Training Technologies Corp. May not be reproduced in any form without written permission. 15
 Incident Investigation: Recommendations, Communication and Follow-Up

QUIZ (continued)

8. In all communication about the incident, start with what happened.

True False

9. When sharing what happened, include the effects on people working

in the area, key factors, the recommended corrective actions and the
lessons learned.
True False

10. The first level of communication is a widely distributed general report.

True False

11. The main purpose of a widely-distributed flyer as a means of

communication is to identify the people involved in the incident.
True False

12. The first part of a recommendation is to make sure the description of

the recommendation is clear.
True False

13. Clearly define what the expected results are from a particular
recommendation and set priorities for each action, identifying which
ones should be completed before operations resume.
True False

14. The first level of a corrective action is to eliminate a hazard to ensure

the incident will never happen again.
True False

16 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
 Incident Investigation: Recommendations, Communication and Follow-Up

QUIZ (continued)

15. Communicating the information you have gathered, the lessons

you’ve learned and your recommended solutions will go a long way
toward preventing incidents from happening again.
True False

16. The third part of a recommendation is to identify the person and

their position that will be responsible for implementing the
recommendation.
True False

17. When recommending corrective and preventive actions, weigh the

severity of hazards, the cost of hazards, and their impact on the
entire organization.
True False

18. The main reason for incident investigations is to make sure you
follow federal guidelines.
True False

19. Evaluate every recommended suggestion for corrective and

preventive actions for its value as a real solution to the problem.
True False

20. The method you use to communicate the recommendation depends

on how broad your intended audience is.
True False

© Coastal Training Technologies Corp. May not be reproduced in any form without written permission. 17
 Incident Investigation: Recommendations, Communication and Follow-Up

ANSWER KEY

1. True.
2. False. Step 6 in the investigative process is to identify at least one
recommendation for each key factor.
3. True.
4. False. Do Not include any recommendations or improvement
suggestions that are not associated with the incident facts
or situation.
5. True.
6. True.
7. False. Not everyone in the organization needs to know ALL
information; only those who will benefit from knowing
should be included.
8. True.
9. True.
10. False. The first level of communication is an official incident
investigation report with a limited distribution.
11. False. The main purpose of a widely distributed general report is to
increase awareness, demonstrate commitment and concern
for people, and help others prevent similar incidents.

18 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
 Incident Investigation: Recommendations, Communication and Follow-Up

ANSWER KEY (continued)

12. True.
13. True.
14. True.
15. True.
16. False. The third part to a recommendation is to identify a completion
date; a time by which the change should be implemented.
17. True.
18. False. The main reason for incident investigations is to protect people
because they are your priority.
19. True.
20. True.

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 Incident Investigation: Recommendations, Communication and Follow-Up

Notes

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20 © Coastal Training Technologies Corp. May not be reproduced in any form without written permission.
Incident Investigation Training Series
• Incident Investigation: Getting Started
• Incident Investigation: Forming an Effective Team and Gathering Information
• Incident Investigation: Analyzing the Facts and Causes
• Incident Investigation: Recommendations, Communication and Follow-Up

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