Incident Reporting and Investigation System
From the first report to a cause actually addressed
The report is the easy part. The handover between report, investigation, action and closure is where the record breaks.
We carry one record from the first report through to the action that closes it, with notification and escalation driven by severity rather than by whoever remembers to make the call. The record slips at the handovers, between reporting and investigation and between investigation and the action meant to prevent recurrence.
The four joints, and what holds them
Reporting to investigation
Where it slips
A report sits in an inbox until someone notices it
What holds it
Severity classification at the point of record triggers the routing automatically
Investigation to cause
Where it slips
The narrative stops at operator error because the form allows it
What holds it
Structured causal fields that will not close while the system conditions are blank
Cause to action
Where it slips
Actions are written loosely and closed without evidence
What holds it
Each action inherits its cause, and closure requires evidence attached
Action to recurrence
Where it slips
The same event happens at another site and nobody connects them
What holds it
Cause codes are searchable across sites, so a repeat surfaces on its own
The clock is not discretionary
Statutory notification clocks run inside the workflow. Under the MSIHC Rules and the Factories Act the timing is not discretionary, and a system that depends on someone remembering the deadline is a system that will eventually miss it.
What good reporting looks like at first
Better reporting looks like worse performance for the first two quarters. Near miss volume rises because the friction came off, not because the plant got more dangerous. Anyone reading the trend needs to be told that in advance.
Carry an incident end to end on one record
We will come back with the workflow, the severity routing and a delivery timeline. Tell us how incidents reach you today and which notification clocks you are bound by.