Analysis of Incident Investigation Reports
Instructions
This assignment addresses course outcome(s) X and module learning objective(s) X [linked to syllabus]. [Provide clear instructions, both
for how the students should complete and format the assignment as well
as information such as the naming conventions they should use and the
file format required for grading and expected response length.]
Purpose:
This assignment will help you apply the principles and processes of incident investigation learned in class to real-world events. You will select and analyze an official investigation report from one of the following sources:
NIOSH FACE Reports (Fatality Assessment and Control Evaluation)
NTSB Investigation Reports (National Transportation Safety Board)
CSB Investigation Reports (U.S. Chemical Safety Board)
Select a Case
Choose one incident report from one of the above organizations.
The report should describe an incident involving worker injury, illness, or fatality, and provide investigative findings and recommendations.
Report Summary
Briefly summarize the incident, including:
Date, location, and setting
Industry and work activity involved
Nature of injuries or fatalities
Immediate events leading to the incident
Investigation Process Evaluation
Describe the investigative steps taken (e.g., scene securing, evidence collection, interviews).
Identify tools, techniques, and stakeholders involved.
Compare these steps to the investigative process outlined in the course chapter—note similarities and differences.
Cause Analysis
Identify proximate and root causes of the incident as determined by investigators.
Evaluate whether the analysis went beyond immediate causes to explore systemic issues.
Discuss if and how the agency used models (e.g., domino theory, Swiss cheese model, or more complex approaches).
Recommendations Review
Summarize the recommendations made in the report.
Assess whether they address root causes or primarily focus on immediate hazards.
Propose one additional recommendation based on your understanding of the case.
Reflection
Discuss what this case taught you about effective (or ineffective) incident investigation.
Reflect on the challenges investigators may face in addressing systemic workplace hazards.
Formatting & Submission:
Length: 5-10 pages, double-spaced, 12-point font
Cite the investigation report and any other sources in APA format
Submit electronically through Canvas by [due date]
Evaluation Criteria:
Clarity and accuracy of case summary (15%)
Depth of investigation process evaluation (25%)
Quality of cause analysis (25%)
Strength and originality of recommendations (20%)
Insightfulness of reflection (15%)
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