Title Page
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Case Type
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Date of Incident
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Injured Parties Name
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Town / County
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HSEQ Advisor
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Sector
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Sector sub-classification
- Private
- Public
- Technical Services
- Workspace
- Group
- Ireland
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Accident Type
- Injury - no first aid
- Injury requiring medical treatment
- Damage only
- Serious injury with possible permanent injury
- Ill health
- Fatality
- Near miss
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Accident Category
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Loss Potential
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A Mandatory Safety Alert to the business is required
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Loss Potential
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A Safety Alert to the business may be required
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A Mandatory Safety Alert to the business is required
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Loss Potential
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A Safety Alert to the business may be required
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Loss Potential
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A Safety Alert to the business may be required
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Loss Potential
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Root Cause Analysis for accident category
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Immediate Causes - Unsafe Acts (select as applicable)
- 1.0 Following Procedures
- 2.0 Use of Tools or Equipment
- 3.0 Safety Risks & Controls
- 4.0 Inattention / Lack of Awareness
- Non-applicable
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Sub-select option(s) from 1.0
- 1.1 Violation by individual
- 1.2 Violation by group
- 1.3 Violation by supervisor / line manager
- 1.4 Operation of equipment without authority
- 1.5 Improper position or posture for the task
- 1.6 Overextension of physical capability
- 1.7 Work or motion at improper speed
- 1.8 Improper fitting
- 1.9 Improper loading
- 1.10 Shortcuts
- 1.11 Other
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Provide details
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Sub-select one option(s) from 2.0
- 2.1 Improper use of plant or equipment
- 2.2 Improper use of tools
- 2.3 Use of defective equipment (aware)
- 2.4 Use of defective tools (aware)
- 2.5 Improper placement of tools, equipment or materials
- 2.6 Operation of plant / equipment at improper speed
- 2.7 Servicing / adjusting of energised plant or equipment
- 2.8 Other
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Provide details
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Sub-select option(s) from 3.0
- 3.1 Unaware of hazards present
- 3.2 PPE not used
- 3.3 Guards, barriers or safety measures were not used, were disabled or removed
- 3.4 Plant, equipment, materials or persons not secured
- 3.5 Other
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Provide details
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Sub-select option(s) from 4.0
- 4.1 Improper decision making / lack of judgement
- 4.2 Distracted by other concerns
- 4.3 Inattention to immediate surroundings
- 4.4 Inappropriate behaviour (horseplay)
- 4.5 Acts of confrontration / violence
- 4.6 Failure to warn
- 4.7 Use of drugs or alcohol
- 4.8 Routine activity without thought
- 4.9 Unwittingly using defective plant, equipment or tools
- 4.10 Other
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Provide details
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Immediate Causes - Unsafe Conditions (select as applicable)
- 5.0 Protective Systems
- 6.0 Tools, plant, Equipment and Vehicles
- 7.0 Work Exposures to
- 8.0 Work Place Environment / Layout
- Non-applicable
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Sub-select option(s) from 5.0
- 5.1 No or inadequate guards or protective systems
- 5.2 No or inadequate PPE
- 5.3 No or inadequate warning systems
- 5.4 No or inadequate isolation of process or equipment
- 5.5 Other
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Provide details
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Sub-select option(s) from 6.0
- 6.1 Defective, inadequate or improperly prepared plant / equipment
- 6.2 Defective, inadequate or improperly prepared tools
- 6.3 Defective, inadequate or improperly prepared vehicles
- 6.4 Other
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Provide details
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Sub-select option(s) from 7.0
- 7.1 Fire or explosion
- 7.2 Noise or vibration
- 7.3 Energised electrical systems
- 7.4 Other energised systems
- 7.5 Radiation
- 7.6 Temperatures / pressure extremes
- 7.7 Hazardous chemicals or infectious agents
- 7.8 Mechanical hazards
- 7.9 Storms or acts of nature
- 7.10 Other
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Provide details
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Sub-select option(s) from 8.0
- 8.1 Congestion or restricted motion
- 8.2 Inadequate or excessive illumination
- 8.3 Inadequate ventilation
- 8.4 Unprotected ventilation
- 8.5 Inadequate work place layout / segregation
- 8.6 Slippery floors or walkways
- 8.7 Inadequate house keeping
- 8.8 Inadequate separation of vehicles / people
- 8.9 other
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Provide details
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System Causes (select as applicable)
- 1.0 Personal Condition
- 2.0 Mental Condition
- 3.0 Behaviour
- 4.0 Skill Level
- 5.0 Design and Risk Management
- 6.0 Management Systems and Work Planning
- 7.0 Safe Systems of Work or Policies, Standards, Procedures
- 8.0 Managing People (Competence, Resourcing)
- 9.0 Contractor Selection and Management
- 10.0 Procurement, Materials handling and Control
- 11.0 Plant, Tools and Equipment
- 12.0 Communication
- Non-applicable
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Sub-select option(s) from 1.0
- 1.1 Inadequate physical capability (senses strength stamina)
- 1.2 Disability (injury, breathing, loss, deafness)
- 1.3 Temporary impairment (fatigue, allergy, alcohol, drugs, medication)
- 1.4 Other
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Provide details
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Sub-select option(s) from 2.0
- 2.1 Well trained but wrong reaction
- 2.2 mental or emotional overload, imbalance or frustration
- 2.3 Low learning aptitude
- 2.4 Extreme demands, judgement or concentration
- 2.5 Extreme boredom or meaningless task
- 2.6 Other
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Provide details
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Sub-select option(s) from 3.0
- 3.1 Manager or supervisor condoned or applied inappropriate behaviour or action
- 3.2 Inadequate identification of critical safe behaviours (haste)
- 3.3 Inappropriate agression
- 3.4 Improper use of production incentives
- 3.5 Personal benefits from improper behaviour
- 3.6 Other
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Provide details
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Sub-select option(s) from 4.0
- 4.1 Requisite skills not identified
- 4.2 Skills not applied
- 4.3 Lack of coaching on skill
- 4.4 Other
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Provide details
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Sub-select option(s) from 5.0
- 5.1 Design not well specified
- 5.2 Risk not assessed
- 5.3 Risk inadequately addressed by design
- 5.4 Appropriate standards not adopted
- 5.5 Control failings in construction or operation
- 5.6 Inadequate commissioning and handover
- 5.7 Safety related software inadequately developed
- 5.8 Other
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Provide details
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Sub-select option(s) from 6.0
- 6.1 Roles and responsibilities not clear
- 6.2 Inadequate working planning or method statements
- 6.3 Inadequate documentation or control of
- 6.4 Inadequate management of change system
- 6.5 Inadequate waste handling disposal
- 6.6 Inadequate incident reporting / investigation system
- 6.7 Inadequate performance measurement, monitoring, audit or inspection
- 6.8 Other
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Provide details
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Sub-select option(s) from 7.0
- 7.1 No or inadequate development of SSoW or PSP
- 7.2 Inadequate implementation of SSow or PSP
- .3 Inadequate management enforcement of SSoW or PSP
- 7.4 Other
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Provide details
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Sub-select option(s) from 8.0
- 8.1 Inadequate leadership or supervision
- 8.2 Inadequate manpower
- 8.3 Inadequate training or briefing
- 8.4 Wrong person for the job
- 8.5 Other
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Provide details
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Sub-select option(s) from 9.0
- 9.1 Lack of contractor pre-qualifications
- 9.2 No or inadequate contractor selection process
- 9.3 Inadequate specification of contractors role or deliverables
- 9.4 Inadequate supervision of contractors
- 9.5 Other
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Provide details
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Sub-select option(s) from 10.0
- 10.1 Inadequate identification, evaluation of materials or equipment
- 10.2 Incorrect item ordered or received
- 10.3 inadequate packing, shipping, storing, handling of materials or spare parts
- 10.4 inadequate salvage or disposal
- 10.5 other
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Provide details
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Sub-select option(s) from 11.0
- 11.1 Inadequate specification or selection
- 11.2 Inadequate adjustment, repair or maintenance
- 11.3 No or inadequate equipment record history
- 11.4 Other
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Provide details
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Sub-select option(s) from 12.0
- 12.1 Inadequate communication within organisation
- 12.2 Inadequate communication between different organisations
- 12.3 inadequate telecommunication transmissions
- 12.4 Inadequate telecommunication procedures
- 12.5 Other
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Provide details
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Please respond to all the following questions. If "Yes" tick the checkbox. If "No" leave blank.
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1. Did a lack of clarity with regard to the task and distribution of competences contribute to the incident?
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2. Did insufficient instruction or a lack of training contribute to the incident?
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3. Did communication difficulties between those involved contribute to the incident?
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4. Did missing or insufficient working instructions, safety rules or labelling contribute to the incident?
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5. Did a failure to follow working instructions, safety rules or labelling contribute to the incident?
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6. Did inappropriate or defective working materials (e.g. tools, equipment) contribute to the incident?
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7. Did insufficient maintenance or repairs (e.g. from structures, plant, working materials, tools) contribute to the incident?
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8. Could the incident been avoided f the proper personal protective equipment (e.g. protective glasses, fall protection) had been correctly worn and maintained?
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9. Did missing, defective or insufficient protective equipment contribute to the incident?
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10. Were the operations previously aware of the danger that led to the incident?
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11. Did the incident occur despite the fact that measures to prevent this incident had previously been taken or mandated?
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12. Have you found any inadequacies in the emergency organisation?
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13. If fire played a role in the incident have you found any inadequacies in the fire protection measures?
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14. Did employees ever draw attention to the danger that led to the incident?
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15. Did deficiencies in the design of the workplace and the work process contribute to the incident?
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16. Did the condition of the injured party (e.g. physical or psychological burden, fatigue, influence from medications or alcohol) contribute to the incident?
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17. Did climatic influences (e.g. heat , cold, wet) contribute to the incident?
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18. Did visibility conditions (e.g. darkness, glare, fog, smoke) contribute to the incident?
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19. Did hazardous materials contribute to the incident?
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* I confirm I have responded to the questions above.* By leaving all the check boxes blank no contributory factor was identified in the descriptions provided. By ticking a check box a contributory factor(s) was identified in the descriptions provided.
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Additional information, comments, notes, explanations;
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Actions
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Action Deadline date(s)
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Completion date(s)
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Action Description(s)
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Description of new or changed risk
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Documents to upload (detail any)
