Accident / Incident Investigation

• Reference

• Site

• Event

• Conducted on

  Date

• Prepared by

• Investigation Team

• Distribution

• Injury / Damage

  Confirmed

  Unconfirmed

• Persons Involved

  Confirmed

  Unconfirmed

• Company

  Confirmed

  Unconfirmed

• Medical Treatment

  Confirmed

  Unconfirmed

• Notifiable

  Confirmed

  Unconfirmed

Incident Description

• Add media

  Media

• Add drawing

  Drawing

Incident Timeline

• Critical event

Critical Event

• Notes:

Contributing Factors

People

Environment

Equipment

Material

Procedures

Organisation

Contributing Factor

Conclusions or Observations

Corrective Action

Action

Corrective Action

Analysis

Individual / Team Action

• Untrained or inexperienced

  Causal Factor

  N/A

• Unfamiliar with equipment

  Causal Factor

  N/A

• Unaware of hazards related to the job

  Causal Factor

  N/A

• Not confident in their ability to complete the task properly

  Causal Factor

  N/A

• Influenced or pressured by peers

  Causal Factor

  N/A

• Influenced by inadequate or inappropriate incentives

  Causal Factor

  N/A

• Trying to save time or effort, avoid discomfort or attract attention

  Causal Factor

  N/A

• Disregard / unsafe act

  Causal Factor

  N/A

• Injured, Ill or fatigued

  Causal Factor

  N/A

• Distracted or preoccupied

  Causal Factor

  N/A

• Angry / stressed etc.

  Causal Factor

  N/A
Individual / Team Action

• Causal Factor

  N/A

Absent or failed defences

• The contributing factors result from inadequate of absent defences that failed to detect & protect the system against technical and human failures.

• Defective

  Causal Factor

  N/A

• Not the correct one to use in the process

  Causal Factor

  N/A

• Inappropriately altered or changed in any way

  Causal Factor

  N/A

• Flammable

  Causal Factor

  N/A

• Potentially harmful

  Causal Factor

  N/A

• Damaged in storage

  Causal Factor

  N/A

• In a changed state (eg. liquid to vapour)

  Causal Factor

  N/A

• Giving off harmful fumes, odours, dusts etc.

  Causal Factor

  N/A
Task absent / failed defences

• Yes

  No

  N/A

Task / Environmental Conditions

• Not suitable for the physical needs of the person

  Causal Factor

  N/A

• Not capable of performing the expected task

  Causal Factor

  N/A

• Not I proper working order

  Causal Factor

  N/A

• Not properly maintained

  Causal Factor

  N/A

• Not safe by design

  Causal Factor

  N/A

• Not constructed without defect

  Causal Factor

  N/A

• Defective due to excessive use, misuse and/or abuse

  Causal Factor

  N/A

• Without the appropriate guards and controls

  Causal Factor

  N/A

• Equipped with necessary warning systems? Were they working

  Causal Factor

  N/A

• The lighting was inadequate

  Causal Factor

  N/A

• Noise or Vibration was a factor

  Causal Factor

  N/A

• Heat or cold was a factor

  Causal Factor

  N/A

• Personal protective equipment was not readily available

  Causal Factor

  N/A

• Path of vision was blocked

  Causal Factor

  N/A

• Equipment and materials were not stored/installed in the designated area

  Causal Factor

  N/A

• Work area was not clean and free of debris

  Causal Factor

  N/A

• The work station was not designed to fit the needs of the individual

  Causal Factor

  N/A

• Warning signs were not in place in designated areas

  Causal Factor

  N/A

• Protruding objects were in the workplace

  Causal Factor

  N/A

• Harmful amounts of contaminants in the air

  Causal Factor

  N/A
Task environmental

• Causal Factor

  N/A

Procedures or Work Method

• No safe system of work

  Causal Factor

  N/A

• Safe system of work inaccurate

  Causal Factor

  N/A

• Safe system of work unknown / not communicated

  Yes

  No

  N/A

• Safe system of work unavailable

  Yes

  No

  N/A

• Safe system of work / best practice not encouraged or reinforced

  Causal Factor

  N/A

• Highest controls not used for the process

  Causal Factor

  N/A

• Personal protective equipment was not being used property

  Causal Factor

  N/A
Task procedures / work methods

• Causal Factor

  N/A

Organisational Failures - Basic Causes

• Lack of Hazard Identification or Risk Assessment

  Causal Factor

  N/A

• Lack of training, skill or knowledge

  Causal Factor

  N/A

• Lack of Change Management

  Causal Factor

  N/A

• Lack of resources

  Causal Factor

  N/A

• Lack of supervision

  Causal Factor

  N/A

• Production expectations in conflict with OHS best practices

  Causal Factor

  N/A

• Programs not in place to encourage OHS procedures and practices

  Causal Factor

  N/A

• Good housekeeping rules not enforced

  Causal Factor

  N/A

• Rules and procedures not enforced appropriately

  Causal Factor

  N/A

• Legislative and company standards not being followed

  Causal Factor

  N/A

• Maintenance and Inspections programs were inadequate

  Causal Factor

  N/A

• Task Organisation Failures

Task Organisational Failure

• Causal Factor

  N/A

Completion

Investigation Review Checklist

• Unsafe conditions corrected

  Yes

  No

  N/A

• Tools / plant / equipment corrected

  Yes

  No

  N/A

• Products / Materials corrected

  Yes

  No

  N/A

• Unsafe work practices corrected

  Yes

  No

  N/A

• Organisational issues corrected

  Yes

  No

  N/A

• All relevant training is up to date

  Yes

  No

  N/A

• Workers counselled where necessary

  Yes

  No

  N/A

• Workers consulted

  Yes

  No

  N/A

• Corrections communication to workforce

  Yes

  No

  N/A

• Investigation review (additional)

Investigation review

• Yes

  No

  N/A

Supporting Information

• Accident / Incident Report

  Yes

  No

  N/A

• Photographs

  Yes

  No

  N/A

• WorkSafe Notification

  Yes

  No

  N/A

• Personnel Inductions

  Yes

  No

  N/A

• Training Records

  Yes

  No

  N/A

• SWMS / Risk Assessments / Work Permits

  Yes

  No

  N/A

• Alerts / Notices

  Yes

  No

  N/A

• Emails and Correspondence

  Yes

  No

  N/A

• Statements

  Yes

  No

  N/A

• Plant Inductions

  Yes

  No

  N/A

• Inspections / Maintenance

  Yes

  No

  N/A

• Plans / Permits / Surveys / Reports

  Yes

  No

  N/A

• Toolbox Talks

  Yes

  No

  N/A

• Certificate of Capacity / Medical Certificate

  Yes

  No

  N/A