ASMC Incident Investigation Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Incident Information

• Investigators

• Employees involved and date contacted

• Summary of Incident

• Add media

  Media

General Incident Questions

• Was there mechanical failure?

  Yes

  No

  N/A

• Was there a procedure to follow?

  Yes

  No

  N/A

• We're safeguards used?

  Yes

  No

  N/A

• In what area does this incident raise concerns?

  Select Engineering Administrative PPE Personnel

  • Engineering
  • Administrative
  • PPE
  • Personnel

• Does the employee have suggestions to avoid a similar incident in the future?

Specific Questions

• Every incident is different and therefore questions must be tailored to the incident. Please use this section to record additional questions asked and their answers.

Incident Investigation Summary

• Recommendations / Findings

• The 5 Whys Analysis. The first why is the direct cause of the incident. Continue to ask "WHY" for the next four or five answers to eventually reach the root cause.

• Undesired event

• Why did the incident happen? (Direct cause)

• Why did this occur? (Contributing cause)

• Why did that occur?(Contributing cause)

• Why did this occur? (Contributing cause)

• Why did that occur? (Contributing cause)

• Root Cause:

• Corrective Actions:

Follow Up Actions

• Select date

  Date

• Add signature

  Sign