Investigation Report

Initial Notification Phase: To be completed by The Supervisor

  • What type(s) of incident occurred?

  • 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:

Injury/Illness Information

  • Body Part Affected:

  • Activity that led to Injury:

Injury/Illness Outcome:

  • What was the outcome (result) of the injury/illness?

  • Truck Unit Number:

  • Type of Travel:

  • Activity that led to Loss

  • Type of VLD:

  • Direct Cause of VLC:

  • 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

  • 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

Safety Department Review & Approval

  • Name, Title

  • Signature

  • Date and Time of Safety Department Sign-off:

Executive Management Review & Approval

  • Name, Title

  • Signature

  • Date and Time of Executive Management Sign-off:

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