DOWBURY ROOFING INCIDENT INVESTIGATION FORM

• Document No.

• Project Name or Job Number

• Client / Site

• Conducted on

  Date

• Prepared by

• Personnel

• Date and time of incident:

  Date

Incident summary from report

• Provide a summary of the incident:

• Add media

  Media

Task being conducted:

• Enter details of task being conducted:

Persons involved / Witnesses

• Name: Position: Location at time of incident:

Immediate Actions:

• List supplementary actions taken:

Time line / Sequence of events:

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

• Add photos as required

  Media

Contributing Factors: Task / Procedural

• Was a safe work procedure available?

  Yes

  No

  N/A

• Was a safe work procedure used?

  Yes

  No

  N/A

• Were controls in place as per the Risk assessment / SWMS?

  Yes

  No

  N/A

• Were appropriate tools and materials available?

  Yes

  No

  N/A

• Were they used?

  Yes

  No

  N/A

• Personnel were trained to conduct the work?

  Yes

  No

  N/A

• The task remained unchanged from original job?

  Yes

  No

  N/A

Contributing Factors: Equipment / Substance

• All equipment was in good working order?

  Yes

  No

  N/A

• Equipment is regularly serviced?

  Yes

  No

  N/A

• Were pre-start checks conducted and correct?

  Yes

  No

  N/A

• Personnel were appropriately trained to operate equipment?

  Yes

  No

  N/A

• SDS are available on site?

  Yes

  No

  N/A

• Appropriate PPE is available?

  Yes

  No

  N/A

• PPE was worn correctly?

  Yes

  No

  N/A

Contributing Factors: Environment / Behaviour

• Weather conditions were not a factor of the incident?

  Select Safe At Risk N/A

  • Safe
  • At Risk
  • N/A

• Area was clean and tidy, poor housekeeper was not a factor?

  Safe

  At Risk

  N/A

• Was it too hot or too cold?

  Safe

  At Risk

  N/A

• Was lighting adequate?

  Safe

  At Risk

  N/A

• Was fatigue evident?

  Safe

  At Risk

  N/A

• Was alcohol or another impairment evident?

  Safe

  At Risk

  N/A

• Was the task being rushed?

  Safe

  At Risk

  N/A

• Were workers complacent?

  Safe

  At Risk

  N/A

• Were health issues a factor?

  Safe

  At Risk

  N/A

• Workers were experienced and adequately supervised?

  Safe

  At Risk

  N/A

Other Contributing factors:

• List any other contributing factors:

• Add photos as required

  Media

Conclusions:

• Enter investigation conclusions:

Recommendations:

• Enter recommendations:

• Signature of investigating officer:

  Sign

• Signature of manager:

  Sign