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BSC Incident Investigation Report V1
BSC Incident Investigation Report V1
Hazard

BSC Incident Investigation Report V1

Conduct investigation and initiate remedial action

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Free BSC Incident Investigation Report V1 Checklist

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Audit / Inspection Details

  • Investigation Title (Insert classification) 1. Injury to worker 2. Plant or equipment damage 3. Near Miss

  • Insert date and time of injury OCCURRED.

  • Insert date and time of injury REPORTED.

  • Report document number:

  • Name of worker and position (if reported as injury)

  • Investigation Officer

  • Department / Client (PCBU)

  • Department Line Manager

  • Team Leader

  • Worksite Supervisor

  • Contact Name and Details

  • Investigation Conducted on:

  • Location

1. Incident Details

1. Insert description of incident details

  • Task being undertaken at time of incident?

  • Description of incident:

  • Media

  • Plant and/or property details:

  • Third party details:

  • Details of injury or damage sustained:

  • Add media

  • Location of incident:

  • Corrective Action?<br>1. Immediate<br>2. Within 24 hours<br>3. Further Controls<br>4. Other

  • Insert SWMS or SWP applicable details.

  • Comments / Recommendations / Corrective action

Risk and HR Department Notified?

  • Risk and HR notified?

  • Name of Risk and HR person notified:

2. Short Term Corrective Action

2. Immediate Corrective Action (Short term or no further action required):

  • Short term remedial action implemented?

  • Add media

  • Short term corrective action completed details

  • Name and signature of person responsible for implementing corrective action

  • Further remedial action required?

    • Yes
    • No
    • Not Applicable

  • Comments / Recommendations / Corrective action

  • Name and signature of person responsible for following-up on additional actions:

3. Team Leader / Supervisor Statement

3. Team Leader / Supervisor Statement

1. Team Leader Statement

  • Add comments and recommendations

  • Add media

  • Date and time of interview

  • Team leader name and signature

2. Supervisor Leader Statement

  • Add comments and recommendations

  • Add media

  • Date and time of interview

  • Team leader name and signature

4. Worker Statement (Injured)

4. Worker Statement (Injured worker/s)

  • Add comments

  • Add media

  • Worker name and signature

  • Add date and time of interview

5. No: 1. Witness Statement

5. No: 1. Witness Statement

  • Add comments

  • Add media

  • Add date and time of interview

  • Worker name and signature

6. No: 2. Witness Statement

6. No: 2. Witness Statement

  • Add comments

  • Add media

  • Add date and time of interview

  • Worker name and signature

7. No: 3. Witness Statement

7. No: 3. Witness Statement

  • Add comments

  • Add media

  • Add date and time of interview

  • Worker name and signature

8. No: 4. Witness Statement

8. No: 4. Witness Statement

  • Add comments

  • Add media

  • Add date and time of interview

  • Worker name and signature

9. Recent Site Info.

9. Recent site visits and recommendations?

Recommendations?

  • Any Recommendations?

  • Add media

  • Recommended actions

  • Name and signature of person responsible.

Controls implemented?

  • Implemented?

  • Add media

  • Description of controls implemented.

  • Name and signature of person responsible.

10. Investigation

10. Investigation

  • 1. Site Description: Prior to and at time of incident

  • Photo evidence

  • Add drawing

  • 2. Plant Description: Prior to and at time of incident, for each plant/equipment or vehicle involved.

  • Add media

  • Add drawing

  • 3. Person/s involved in incident: Background, experience and evidence of competence.

  • Photo evidence

  • Add drawing

  • 4. Other

  • Photo evidence

  • Add drawing

11. Cause of Incident: Investigation

11. Part C: Cause of Incident: Factors contributing to the cause of accident?

1. Work Process or Task Factors?

  • 1. Inadequate or no risk assessment?

  • 2. Deficient or no SWMS?

  • 3. Worker not following SWMS?

  • 4. Work pressures: Inadequate staff?<br>- Other?

  • 5. Chemicals: No safety data sheet (SDS)

  • 5. Chemicals: Worker not trained in the use if SDS?

  • 6. Inadequate tools or equipment provided for work?

  • Add media

2. Work Material Factors?

  • 1. Equipment failure?

  • 2. Equipment design failure?

  • 3. Faulty or in-serviced equipment?

  • 4. No or inadequate worker induction into site or activity?

  • 5. Lack of correct training?

  • 6. Unsatisfactory supervision?

  • 7. No or inadequate personal protective equipment (PPE)?

  • Add media

3. Environmental?

  • 1. Work area design contributed to incident?

  • 2. Weather conditions? (Wet, slippery, hot, windy etc.)

  • 3. Noise related?<br>- Noise exceeding limits?<br>- High impact noise?

  • 4. Toxic fumes?

  • 5. Poor housekeeping?<br>- Materials laying around?<br>- Work area left un-tidied after use?<br>- Equipment no t stored or secured properly?

  • Add media

4. Personnel Factors?

  • 1. Inadequate or no General WHS Induction into safety systems?

  • 2. Inexperienced?

  • 3. Not assessed for competence?

  • 4. Not trained properly?

  • 5. Health issues contributing to incident?

  • 6. Physical disability: Work expectation unreasonable?<br>- Other?

  • 7. Was fatigue a factor? <br>- What contributed to fatigue?<br>E.g. Workload, social, health?<br>Other?

  • 8. Were safe work procedures followed (If available)?

  • 9. Was the incident due to not following reasonable instruction?

  • 10. Was the worker working in a safe and responsible manner?

  • Add media

12. Remedial Action

12. Remedial Action and Risk Rating (Please insert details of control introduced and re-rate risk).

  • 1. Review of site rules initiated?

  • 2. Site specific risk assessment reviewed?

  • 3. Safe Work Method Statement (SWMS) reviewed? (LIST SWMS NUMBER REVIEWED).

  • 4. Safe Work Procedure (SWP) reviewed?

  • 5. Further training required for worker/s?

  • 6. Worker/s require improved supervision?

  • 7. Plant and equipment inspection and maintenance program to be modified/improved?

  • 8. Workers to improve on housekeeping worksite?

  • 9. Fatigue: Hours of work to be reviewed in relation to type of work?

  • 10. Workers require training on Council health surveillance support program e.g. Social or psychological issues etc?<br>Nominate?

  • 11. Worker employment performance management checked?

  • 11. Activate disciplinary policy and notification to workers?

  • Add media

13. Final Outcomes

13. Final Remedial Action (No further action required unless circumstance change):

  • Type of remedial action implemented?

  • Add media

  • Remedial action completed details and risk rating:

  • Name and signature of person responsible for implementing remedial action:

  • Further remedial action required?

    • Yes
    • No
    • Not Applicable

  • Further comments, recommendation for remedial action?

  • Name and signature of person responsible for following-up on additional actions:

  • Suggested timeframe for further remedial action? Cost in relation to additional actions?

14. Insurance Claims

Insurance Claims?

  • 1. After completing investigation, will an insurance claim be lodged?

  • 2. Public liability Insurance?

    • Yes
    • No
    • Not Applicable

  • 3. Workers Compensation?

    • Yes
    • No
    • Not Applicable

  • 4. Motor Vehicle?

    • Yes
    • No
    • Not Applicable

  • Add media

Investigating Officer Comments and Details

Investigation Officer/s Comments and Recommendations

Investigator 1.

  • Comments

  • Add media

  • Name, title and signature of person conducting compliance audit

Investigator 2.

  • Comments/Recommendations

  • Add media

  • Name, title and signature of person conducting compliance audit

Investigator 3.

  • Comments

  • Add media

  • Name, title and signature of person conducting compliance audit

Line Manager

Line Manager: Comments and Recommendations

  • Comments/Recommendations

  • Name, title and signature of person conducting compliance audit

  • Date and Time

Team Leader

Team Leader: Comments and Recommendations

  • Comments/Recommendations

  • Name, title and signature of person conducting compliance audit

  • Date and Time

Site Supervisor

Site Supervisor: Comments and Recommendations

  • Comments/Recommendations

  • Add media

  • Name, title and signature of person conducting compliance audit

  • Date and Time

Worker Names, Titles and Signature

Workers On-site, Names, Titles and Signature on worksite

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

  • Name of worker and signature (Add title if required)

BSC Incident Investigation Report V1
Hazard

BSC Incident Investigation Report V1

Conduct investigation and initiate remedial action

Use this Template
The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.

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