Title Page
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Site conducted
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Conducted on Date
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Prepared by
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Reference number
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Incident Summary (reason for investigation)
Incident details
Incident Category:
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What is the incident category?
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Level One investigation is required
Designate Team
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Team Leader:
Team Members:
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Name of team member
Define Problem
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When was the incident?
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Where did the accident occour in the facility?
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What process was involved in the incident (include the process number and add as .pdf)?
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Who was involved (please use initials only)
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What is their employment status?
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What is their shift pattern?
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What was the incident type?
- Documentation Error
- Financial Error
- Customer Complaint
- Internal Issue
- Audit non-conformance
- Other
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Has this person received training in the task where the accident occurred?
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Provide evidence of training such as certificate or attendance record
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What level of experience does this person have?
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Please describe the incident in detail (sticking to facts known - not assumptions)
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What was the immediate response?
- Quarantined the area/ equipment
- Communication to effected parties
- Reported to line manager
- Other
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Describe the immediate response
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How was communication delivered?
- Phone Call
- Heads Up
- Face to Face
- Whats App/ Text
- Other
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Who was contacted by phone call?
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What was communicated?
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Who was contacted?
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What was communicated?
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Describe communication route
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How was quarantine implemented?
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Where was quarantine implemented?
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Who was reported to?
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Were any witness statements documented?
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Please attach the documents
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Was Violence or Aggression involved?
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The HR department must be involved
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This incident requires a brief investigation
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When was the incident?
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Where did the incident occur in the facility?
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Who was involved (please use initials only)
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What is their employment status?
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Describe the incident
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Has their manager been informed?
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Describe what has been put in place to stop the issue from escalating?
- Human factors
- Materials
- Measurement
- Equipment
- Process
- Environment
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What corrective actions have been implemented to improve the human factor cause of this accident?
- Lessons Learnt communicated
- Re-trianing
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
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What corrective actions have been implemented to improve the materials used in this accident?
- New supplier
- Improved materials
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
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What corrective actions have been implemented to improve the measurement aspects of this accident?
- Re-calibration
- Delays managed
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Describe corrective action implemented
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Has this action been completed?
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What corrective actions have been implemented to improve the equipment used in this accident?
- Fixed equipment
- Quarantined equipment
- Disposed of equipment
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Describe the action required to improve the equipment used in the accident
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Has this action been completed?
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Has this action been completed?
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What corrective actions have been implemented to improve the process related to this accident?
- Process reviewed
- Process written
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
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What corrective actions have been implemented to improve the environment associated with this accident?
- Improved waste management
- Additional spill equipment
- Controlled work area
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
Sign off
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No further investigation is necessary and the template can be finished here
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Name of person reporting incident
Full Investigation of Incident
Interim Containment
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Describe what has been put in place to stop the issue from escalating?
- Human factors
- Materials
- Measurement
- Equipment
- Process
- Environment
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What corrective actions have been implemented to improve the human factor cause of this accident?
- Lessons Learnt communicated
- Re-trianing
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
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What corrective actions have been implemented to improve the materials used in this accident?
- New supplier
- Improved materials
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
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What corrective actions have been implemented to improve the measurement aspects of this accident?
- Re-calibration
- Delays managed
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Describe corrective action implemented
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Has this action been completed?
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What corrective actions have been implemented to improve the equipment used in this accident?
- Fixed equipment
- Quarantined equipment
- Disposed of equipment
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Describe the action required to improve the equipment used in the accident
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Has this action been completed?
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Has this action been completed?
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What corrective actions have been implemented to improve the process related to this accident?
- Process reviewed
- Process written
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
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What corrective actions have been implemented to improve the environment associated with this accident?
- Improved waste management
- Additional spill equipment
- Controlled work area
- Other
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Please describe the action implemented
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
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Has this action been completed?
Verify and Determine the root cause
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You can use the simple Ishikawa principle to determine a potential root cause as a brain storming tool with the colleagues or the 5 Why process
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Which root cause analysis will you use?
- 5 Why
- Ishikawa
- Other
5 Why Analysis (click the green + button to complete)
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What is the problem you are going to root cause analyse
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Why?
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Why?
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Why?
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Why?
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Why?
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As determined by the 5Why above, what are the Immediate/Direct Causes (circumstances that immediately precede the accident)
- Slip
- Trip
- Stab / Puncture
- Cut / Laceration
- Lifting / Carrying
- Pushing / Pulling
- Fall (same level)
- Fall from height
- Unauthorised use of equipment
- Not wearing required PPE
- Not following training
- Struck by moving vehicle
- Equipment Fault or Failure
- Personal attack
- Contact with moving machinery
- Struck by falling / flying objects
- Contact with electricty
- Struck against fixed / stationary object
- Removal of safety guards
- Exposure / contact with harmful substance(s)
- Burns / Scalds from exposure to Fire or Heat
- Trap or Pinch
- Horseplay
- Non- Injury i.e. fainting, nose bleed, black out, rash, bee sting, etc.
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As determined by the 5Why above, what is the Basic/Root Cause for the accident?
- Personal/ Human Factors
- Job/ System Factors
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What was the Person/ Human Factor Root cause?
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What is the job/ system factor of the root cause
Define and implement Corrective Actions (e.g what actions can be taken to rectify the root causes identified in previously)
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Include a Actions and assign a SMART objective
Verify Permanent Corrections (PCs) for Problem
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Can the issue be recreated by removing one or more of the results identified in section 5?
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Can the problem be corrected again by reinstating the results identified above?
Prevent Recurrence
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Has the problem has reoccurred since implementation of all actions.
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The root cause analysis should be reviewed and additional prevenatative actions implemented
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Has the procedure/ process been updated?
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Have the results and improvements been communicated to all affected persons?
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Has the corrective action been witnessed?
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If the answer is yes to all of the above in this section, then the investigation is ready to be closed
Sign off
End of Investigation - Sign off
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What time was lost due to the accident (mins/ hours/ days)?
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Team Leader sign off:
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First Aider sign off:
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Completion Date