• Incident Number

  • Conducted on

  • Prepared by

  • Personnel Involved In Investigation

  • Synergy Reference Number

Assess the Risk:

  • Assess the risk of this incident/accident or hazard.
    Note left of the blue line represents an Insignificant incident/accident or hazard.

    no label
  • The risk assessment rating is:-

  • Is this an insignificant incident or accident?

  • Provide details:

Details from incident/accident or hazard form:

  • Include a photo of the insignificant incident or accident.

  • Quote the incident/accident or hazard reference number:

  • Add media

  • Was the event a hazard?

  • If this incident/accident is insignificant please go to the end of the investigation form, complete the Conclusion, Summary Actions and sign.

    Email completed incident/accident investigation form to Depot Admin Coordinator for processing.

Task being conducted:

  • Enter details of task being conducted:

  • Include location of incident/accident or hazard
  • Include date and time of incident/accident or hazard

Persons involved/Witnesses:

  • Name/s and Position/s

Reference documentation:

  • Enter Details.

Immediate Actions:

  • List immediate actions taken as a result of the incident:

Supplementary Actions:

  • List supplementary actions taken:

Time line / Sequence of events:

  • Enter the sequence of events from initial report and interviews:

  • Add photos as required

  • Draw a picture or diagram if this assists with explanation

Contributing Factors: Task / Procedural

  • Was a Prestart undertaken?

  • Was a safe work procedure available?

  • Was a safe work procedure used?

  • Was the procedure appropriate?

  • Were appropriate tools and materials available?

  • Was a risk assessment conducted?

  • Were controls in place as per the Risk assessment?

  • Were they used?

  • Personnel were trained to conduct the work?

  • Was a JSA completed noting all hazards?

  • The task remained unchanged from original job?

  • Were change management principals used?

  • Was a Traffic Management Plan in place?

  • Was the site made safe to the public?

  • Was the site made safe to staff prior to work commencing?

Contributing Factors: Equipment / Substance

  • What was the plant number/s of the equipment involved in the hazard/incident?

  • Has the Workshop Supervisor been notified of equipment/plant damage?

  • Does the Workshop Supervisor need to be involved in the investigation?

  • All equipment was maintained in good working order?

  • Was the equipment used as designed?

  • Could alternative equipment have been used?

  • Equipment has received scheduled workshop servicing?

  • Were pre-start checks conducted and correct?

  • Personnel were appropriately trained to operate equipment?

  • MSDS are available on site?

  • All labels and signs in place and easy to read?

  • Appropriate PPE is available?

  • PPE was worn correctly?

Contributing Factors: Environment / Behaviour

  • Were weather conditions appropriate to complete the task at the time?

  • Was housekeeping or work area clean, tidy and adequate?

  • Were noise levels at the site low enough not to have been a factor?

  • Was lighting adequate?

  • Were you alert and not suffering from fatigue?

  • Did you have enough time to complete the job or task?

  • Were you paying full attention to the task?

  • If you are required to wear visual aids were you wearing them?

  • Were workers adequately supervised?

  • Were workers experienced to perform the task?

Other Contributing factors:

  • List any other contributing factors:

  • Add photos as required


  • Review the Contributing Factors Sections and analyse any Red "NO" responses to conclude. The investigation revealed:-

  • Include additional photos if required


  • Use the Hierarchy of Controls to assist with recommendations, solutions, actions or controls

  • Eliminated? Eg. Discontinued use of product, equipment, ceased work process

  • Actions to be taken

  • By Whom

  • By When

  • Substituted? Eg. Replaced with similar item that does the same job but with a lower hazard level

  • Actions to be taken

  • By Whom

  • By When

  • Isolated? Eg. Put barriers between the person and the hazard

  • Actions to be taken

  • By Whom

  • By When

  • Engineered? Eg. Change the process, equipment or tools so the risk is reduced

  • Actions to be taken

  • By Whom

  • By When

  • Administered? Eg. Are there guidelines, procedures, rosters, training etc in place to minimise the risk

  • Actions to be taken

  • By Whom

  • By When

  • PPE? Eg. Was equipment worn to provide a temporary barrier

  • Actions to be taken

  • By Whom

  • By When

  • By When

  • Summary of Actions:

  • Include additional photos if required.

  • Signature of investigating officer:

  • Signature of manager:

  • Signature of OHS Representative

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.