Information
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Accident - Incident - Near Miss
Investigation Form -
Audit Title
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Document No.
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Project
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Project number
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Conducted on
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Prepared by
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Location
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Personnel
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Who was involved?
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Reported to OH & S branch
Causation
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Date
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Time
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Immediate or direct causes.
Immediate direct causes of accidents/incidents may be attributed to substandard practices or substandard conditions. Immediate direct causes are symptoms of deeper problems.
Substandard Practices
- Is "any departure from an accepted, normal, or correct procedure or practice that permits the occurrence of an accident/incident."
Substandard condition
- Is "any hazardous arrangement which, if left uncorrected, may lead to an accident/incident." -
What was the immediate or direct cause?
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Underlying or indirect causes.
The following maybe used as a guide:
- Worker unsuitable for assignment
- Lack of adequate training
- Safe job procedure not developed
- Safe job procedure not followed or enforced
- Safety equipment not provided
- Lack of proper instruction
- Deliberate disregard for safety regulation
- Lack of regular safety inspection
- Hazards not recognized
- Lack of maintenance system
- Lack of a lock out system
- Substandard design
- Use of drugs / alcohol -
What were the underlying or indirect causes?
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Was a hazard assessment done?
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Why was a hazard assessment not completed?
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Did the hazard assessment recognize the hazard?
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Was training given for the task?
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Describe the training worker received for assigned task.
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Explain why training was not given.
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Was instructions provided before the near miss?
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What instructions have been provided?
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Explain why training was not given.
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Were cautions given?
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What cautions were given?
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Explain why training was not given.
Prevention and Recommendations
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How can similar scenarios be prevented in the future?
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Recommendations for further action
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Recommendations completed by:
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When will the recommendations be completed?
Accident - Incident - Near Miss Scene
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Tap for picture of scene
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Drawing not to scale
North ^ -
Tap to draw the scene
Sign off
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Worker
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Supervisor
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Reviewed by senior management.
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Date:
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Comments or recommendations.