Report writing for RAIB –

Challenges and techniques

Stuart Johnson
Principal Inspector
31 October 2017
The audience
• RAIB’s reports are written for the public and the
industry
• They must be accessible to the informed layman,
without ‘dumbing down’
• They must be accurate and complete
The writers
• RAIB’s reports are written by the investigators
themselves
• More than one investigator may contribute sections
of the text
• They are reviewed by colleagues and managers
The template
• Reports need a structure that is well defined but
flexible
• The RAIB template has been developed over the
whole life of the Branch
• It is intended to guide reports into a format which
is logical, clear, comprehensive and consistent
Key facts and analysis
Background information
Add any background information that is needed to help the reader’s understanding of the causal factors
29. {add text}
30. {add text}

Identification of the immediate cause

31. {describe the immediate cause} [Do not preface this with ‘The immediate cause was…..]
32. {add text to describe the evidence that this was the immediate cause, if necessary}

Identification of causal factors

33. The accident occurred due to a combination of the following causal factors:
a. {add text identifying the first top level factor} (paragraph 34)
b. {add text identifying the second top level factor} (paragraph 41)
c. {add text identifying the third top level factor} (paragraph 48)
Each of these factors is now considered in turn.
Broad subject area 1 [this should be the subject (eg ‘the condition of the track’ or ‘the actions of the driver’) that encompasses top level
causal factors (may be one or more) - should never read as a conclusion but should instead simply introduce the reader to the subject
that is to be discussed]
34. {Add headline that states the first top level factor – single sentence or short paragraph}. This text should be a repeat of 33 a. If
there is some doubt about the presence of this factor, or its relevance to the cause of the accident, it should be qualified by the
words ‘It is probable/possible that this factor was linked to the cause of the accident’
35. {Add facts and analysis supporting the above}
The analysis
• The immediate cause of an accident is the factor that directly resulted
in the occurrence of the accident or incident (it is often simply a
statement of the inevitability of the accident, eg ‘the person was
standing in a position where they could be struck by the approaching
train’).
• Factors that describe the key accident causation themes which
contributed to the occurrence of the accident or incident are referred to
as causal factors. Avoiding or eliminating a causal factor would have
prevented the occurrence.
• Factors that are associated with the overall management systems,
organisational arrangements or the regulatory structure are referred to
as underlying factors.
• An element discovered as part of the investigation that did not have a
direct or indirect effect on the outcome of the accident, but which
deserves scrutiny is referred to as an observation.
The style guide
• The style of a report should be unobtrusive, so that
there is no barrier between the reader and the
content.
• RAIB’s house style has been developed from good
practice used in the Civil Service and elsewhere
• Clarity and consistency are fundamental
The illustrations
• A good diagram can save pages of text
• RAIB makes use of several types of graphics
software, according to the abilities and preferences
of inspectors.
• Pictures need captions and labels, which must
complement and not obscure.
• Photographs may not be clear enough to tell the
story
The review
• Analysis: are the conclusions supported by
evidence?
• Content: is the descriptive material clear and
sufficient?
• Presentation: is the quality of the writing up to
standard?
• Text: are the grammar, spelling and punctuation
correct?
The summary
• The only part that many people will read
• Should be under one page, but can be longer if the
report is complex
• Likely to be used as the basis for press reports and
magazine articles
• If the report is good, the summary is easy to write
• The converse is also true- if it is hard to summarise
a report, there may be something wrong with the
logic
Other approaches
• Sometimes you have to use a closely defined
format
• Terms used (eg “underlying cause”) may have a
different meaning
• Jargon terms (eg “bow tie”) may be acceptable if
they are in general use in the organisation and if
everyone understands them
• It is still possible to produce a clear and effective
report
Using a company template

Jimmy Pettitt
Route Accident & Assurance Investigator
Network Rail LNW
A guide to writing a Local Investigation Report

This guide will assist you to understand how

to write a good investigation report.

The guide will cover each section of a local

investigation report to help you understand
what is required, what good looks like and
what shouldn’t be included.

The guide will cover the following sections:

• A - Event summary, conclusions, recommendations and

local actions
• B Purpose
• C Details
• D People Involved
• E List Of Evidence Used
• F Factors Discussed
• G Behavioural Cause
• H Incident factor causal analysis
• I Signatures
• J Appendices
Section A: event summary, conclusions, recommendations and local actions

• Summary, immediate cause & underlying causes(s)

This section gives a brief summary of what happened and details the immediate
cause/behavioural cause(s) identified The summary is a brief description of the event.

You don’t need to include technical details such as

ELR, mileages etc. these will be included in the body
of the report.

In this hypothetical example, we explain how a driver

passed a signal without the signaller’s authority
resulting in a SPAD.
Just state the fact here , the detail and reasons why
are discussed within the report.

Watch out for your formatting! A2.1 is missing here

State the behavioural cause(s) here and signpost to
where they are discussed. There may be more than
one identified!
Here we have a behavioural cause for the driver but
not the PICOP or signaller.

Don't forget to signpost where your discussion and

evidence to back up your conclusions is contained
within the report.
Section A.5: Bow Tie control failures

What is a Bow Tie? Bow Tie risk assessment method

Business Critical Rules use the Bow Tie method to visualise our complex risks in an easy to understand way.

A Bow Tie starts by looking at the top risk event – or something that is likely to cause harm. It then visualises the things that might
cause the top risk event, the threats, and the consequences of it happening.

Finally it identifies the controls to be put in place to mitigate the risks and shows who is responsible and accountable for those
controls.

As lead investigator you need to

check if there is a suitable Bow Tie
published here:

list of published Bow Tie risk

assessments

And if so document what barrier(s) or

control(s) failed to allow the top
event or consequence to occur.
 Section C: Details

This section describes the location where the incident occurred and any trains,
vehicles, equipment or infrastructure that was involved.
In this example the incident takes place in
the Rugby area, the reader may not be
familiar with the area so a diagram is
always useful.

Include an extract of the Sectional Appendix

if possible, a Google map is also a good
way of showing the location.
Here we see Microsoft Word has underlined
WCML in green.
Choose ‘ignore’ on this to improve the look
or add it to your dictionary.
 Section C: Details continued

This section lists a description of any trains, vehicles, equipment or infrastructure

involved.
C2 details any trains or road vehicles involved.
It is good practice to include a picture of the train or road
vehicle (the actual train involved is preferred but a stock
image of the same model is ok, just let the reader know it is
a stock image).

The level of detail required will depend on how

relevant the train is to the investigation report. For a
SPAD the performance and characteristics of the train
will be discussed in greater detail within the report.

Here we include a description of the signal but this

could also be a PLB, hand trolley or some other
equipment relevant to the investigation.

Annotate the image if needed to further clarify the

equipment
 Section F: Factors discussed

This section should contain the most detail within the report.

The factors discussed should contain a section for each

‘underlying cause’ and any ‘other safety related’ event
listed in section A of the report.

It’s good practice to order them in a logical sequence in

line with the order of the underlying causes etc.

This will help your reader find the right discussion for
each causal factor.
Use the remit issued by the DCP as a guide to what you
need to discuss.

In this paragraph the gender of the signaller has

appeared.
Names or gender of individuals involved have no place in
an investigation report.
 Common pitfalls and errors

Technical detail in Underlying causes Lack of evidence to

the description of listed without due support a theory
the event discussion
Poor or no Lack of union Poor grammar and
referencing in the observers or spelling (remember
report suitable subject it’s a formal
matter experts document)
Underlying causes Lack of explanation Names and
listed as immediate of technical terms personal
cause information
included in the
report
A Guide to writing a Local Investigation Report

additional support and reading material

accident & Investigation page on Connect

The documents above can be downloaded at:

http://connect/assurance/SafetyAndCompliance/AccidentInvestiga
tion/investigation-guides.aspx
Thank you for listening.

Any questions?