Detailed Industry Investigation Report

Title Page

SECURE THE SCENE: Before completing this report, and immediately following reporting the incident to your Supervisor, secure the site of the incident, the equipment involved, and any evidence against tampering, movement, alteration, or removal from the scene.

INITIAL NOTIFICATION: To be completed by the Injured/Involved Person (if possible)

NOTE: The Initial Notification phase of this Report must be completed within three (3) hours of the incident occurrence.
Date and time the incident occurred
In what area did the incident or Near Miss Occur?
Select the type of incident that occurred
- Near Miss / PSIF
- Injury / Illness
- Asset Damage
- Environmental Damage
- Logistics Accident
Briefly describe the incident as soon as possible following the incident. Give your best recollection of the events as they occurred without speculation. Give only the facts.
Date and time the incident was reported to the Supervisor
Was the Supervisor notified of the incident immediately?
Date and time the incident was reported to the Supervisor
Explain the reason(s) the Site Supervisor / Company Man was not notified immediately.
When was the Site Supervisor / Company Man notified?
Who notified the Site Supervisor / Company Man?
Initial Notification prepared by
Reporter's phone number
Supervisor's name
Location
Check the box to confirm the Supervisor has been assigned an Action Item (paperclip to the right) stating this Initial Notification is complete and the Investigation Report needs to be conducted, then sign below.
STOP HERE if you are the Injured/Involved Person (IP) and sign this Initial Notification below. If you are a Supervisor, continue with the Investigation Report AFTER assigning yourself the above required Action Item and signing this Initial Notification below.
Report initiator's signature

Investigation Report

Initial Notification Phase: To be completed by The Supervisor

What type(s) of incident occurred?
- Near Miss
- PSIF - Potentially Serious Injury or Fatality
- Injury / Illness
- Asset Damage
- Environmental Damage
- Logistics Accident
Description of the situation before and leading to the incident.
Add associated pictures with descriptions
Description of work and events as they transpired and resulted in the incident.
Add associated pictures with descriptions
Description of the situation immediately following the incident, e.g., site control, preservation, and security.
Add associated pictures with descriptions
Notify your Superintendent and Safety Representative of the incident, sign below, and continue with the Initial Investigation Phase in collaboration with your Safety Representative.
At this point, the Initial Notification Phase is complete. The Supervisor now assigns an Action Item to their Superintendent (paperclip to the right) to initiate the appropriate Notification Protocol, ensuring incident information is distributed as needed.
Investigating Supervisor's signature

Incident Investigation Phase: To be completed by Safety and the Supervisor

Type of Incident:
- Near Miss
- PSIF - Potentially Serious Injury or Fatality
- Injury / Illness
- Asset Damage
- Environmental Damage
- Logistics Accident

Injury/Illness Information

Body Part Affected:
- Head, neck, face
- Shoulder
- Arm
- Hands, Fingers
- Chest
- Abdomen
- Lower Back
- Pelvis
- Leg
- Knee
- Ankle, Foot, Toe
- Respiratory System
- Central Nervous System
- Digestive System
- Circulatory System
Activity that led to Injury:
- Stepping (Walking)
- Manual Lifting
- Chemical Handling
- Driving
- Handling (Using Hands)
- Mechanical Lifting
- Noise
- Pressure
- Working at Heights
- Temperature Extreme
- Fire/Explosives

Injury/Illness Outcome:

What was the outcome (result) of the injury/illness?
- Near Miss
- First Aid
- Medical Treatment (OSHA Recordable)
- Restricted Modified Work (OSHA Recordable)
- Lost Time (OSHA Recordable)
- Fatality (OSHA Recordable/Reportable)
Truck Unit Number:
Type of Travel:
Activity that led to Loss
Type of VLD:
- Hit vehicle in front
- Hit from behind
- Backed into
- Hit stationary object
- Hit pedestrian
- Sideswiped
- Hit and Run
- Hit an animal
- Ran off the road
- Head on collision
Direct Cause of VLC:
- Aggressive Driving
- Fatigue
- Backing
- Drug/alcohol use
- Distracted Driving
- Driving to fast for conditions
- Following too close
- Nature/ Natural conditions
- Improperly securing items
- Pre Use inspection
- Improper planning
- 3rd party
- Inexperience with driving conditions
Repair Cost Estimate
Type of Environmental Damage:
Describe/List the chemical/contaminating agent and estimate the amount (e.g., gallons, barrels, etc.) involved
What was the risk potential:
Date of operator training:
Daily pre-use inspection:
Asset Number:
Please attach supporting documentation (via email to the appropriate Safety Representative) and answer the questions as applicable. If the answer is No or N/A, please explain the response selection.
Was the incident scene safe, secured, and undisturbed?
Were all injured personnel cared for as fast as was reasonably practicable.
Were the ERT, Security, and/or First Responders notified expediently?
Post incident Drug and Alcohol test
Injured or involved person(s) detailed written statement of events
Witnesses' written statement(s) of events
Pictures of the employee, equipment involved, and include up-close, detailed pictures and overall site pictures (i.e., pictures taken from a distance)
Top-view site schematic of injury/incident scene which including where the injury occurred, where equipment was, and where personnel were located
Pictures of employee body position at time of injury
Evidence of any PPE worn and condition of PPE (pictures if possible)
Evidence of applicable informational/warning signs
Copy of Preliminary Risk Assessment / Take 10
Copy of all associated work permits
Copy of injured or involved person`s training record and associated training for work being performed
Copies of equipment pre-use inspection and last evidenced checks/service
Copy of any communications related to the injury/incident

Jobsite Conditions

Weather
- Day
- Night
- Sunny/Clear
- Overcast
- Raining
- Snowing
Temperature

Contractor or Employee info

Was a PRA (If applicable) and/or an equipment pre-use inspection (If applicable) completed prior to the incident?
Hours on shift in the 24 hours prior to incident
Hours SINCE last sleep prior to current shift
Hours the employee slept prior to the current shift
Days worked in a row
Number of days employed at time of incident
Is the involved injured person a contractor?
Contractor Company:
Did the Contractor employee complete the Optimus Contractor Orientation?
Date of Orientation completion:
Investigating Supervisor's signature
Safety Department Representative's signature

Final Phase: Causal Factors to be completed by Safety Department Representative

Causal Factor 1
Description of why this cause was selected
Causal Factor 2
Description of why this cause was selected
Causal Factor 3
Description of why this cause was selected

Corrective Action Items.

(Please add your descriptive action items to include creating a "Action" to address Causal Factors, Responsible Party and Date Due)
1. <>
a. Task: <
>
Checking this box certifies the Action Item (paperclip to the right) has been assigned.
b. Due Date: <>
c. Accountability: <>
2. <>
a. Task: <
>
Checking this box certifies the Action Item (paperclip to the right) has been assigned.
b. Due Date: <>
c. Accountability: <>
3. <>
a. Task: <
>
Checking this box certifies the Action Item (paperclip to the right) has been assigned.
b. Due Date: <>
c. Accountability: <>
Investigating Safety Department Representative's signature