AVON - Incident Investigation

• Employee Name

• Incident Type

  Near Miss

  First Aid

  Recordable

• Primary Department

  Select Storage Ingredient Preparation Processing/Kitchen Filling Sterilizing Packaging Warehouse Logistics Maintenance Services/Utilities Cleaning/Sanitation Office Laboratory Packaging Manufacture Other

  • Storage
  • Ingredient Preparation
  • Processing/Kitchen
  • Filling
  • Sterilizing
  • Packaging
  • Warehouse
  • Logistics
  • Maintenance
  • Services/Utilities
  • Cleaning/Sanitation
  • Office
  • Laboratory
  • Packaging Manufacture
  • Other

• Incident Location or Line

• Date and Time

  Date

• Incident Description

• Actual severity

  Near Miss

  Minor/First Aid

  Moderate

  Serious

  Severe

• Worker type

  Select Kraft Heinz Employee Agency Temporary Worker Contractor Fixed Contractor Maintenance Visitor Other N/A

  • Kraft Heinz Employee
  • Agency Temporary Worker
  • Contractor Fixed
  • Contractor Maintenance
  • Visitor
  • Other
  • N/A

• Name

• First Name

• Last Name

• Potential severity

  Minor

  Moderate

  Serious

  Severe

• Immediate actions taken

• Reported by

• Supervisor

• Date reported to supervisor

  Date

• Did anyone see this happen?

  Yes

  No

  N/A

• Who

• Activity

  Select Response to problem Routine task Maintenance Cleaning/Sanitation Non-routine task Normal activity By-stander

  • Response to problem
  • Routine task
  • Maintenance
  • Cleaning/Sanitation
  • Non-routine task
  • Normal activity
  • By-stander

• Consecutive days worked prior to incident

• Hours on shift

  1st hour

  Between 2nd & 8th hour

  Over the 8th

• Length of time on the job when incident occurred (years)

  Select <1 1-2 3-5 6-8 9-11 12-14 >15

  • <1
  • 1-2
  • 3-5
  • 6-8
  • 9-11
  • 12-14
  • >15

• In training

  Yes

  No

  N/A

• Team members present

5W1H

• WHAT - what does the problem look like? What product, machine, material is being used? What size?

• Material, Machine & Size:

• WHEN - When did the problem occur? when in the sequence of operation (i.e. start up, continuous running, intermittent problem, shutdown, changeover)?

• Time:

  Date

• WHERE - Where did you see the problem? Where on the equipment or material did you see the problem?

• WHO - Who does it affect? Everyone? Or is it a problem for some individuals or teams? What info can individuals of the team offer? Is it skill related?

• WHICH - Which trend or pattern does the problem have? (i.e. is the problem more frequent on Monday? In the morning? After changeovers? Which direction does the problem happen in? Or is it random?

• HOW - How is the state of the equipment changed from the optimal or standard? How many times does the problem occur?

• Revised Description of problem:

Observations

• Unsafe Condition

• Unsafe Condition

• Unsafe Act(s)

• Unsafe Act(s)

Countermeasures

• Countermeasure 1

• Responsbile

• Date-planned

  Date

• Countermeasure 2

• Responsbile

• Date-planned

  Date

• Countermeasure 3

• Responsbile

• Date-planned

  Date