Provide a summary of the incident:
Enter details of task being conducted:
Name: Position: Location at time of incident:
Work activity briefing?
List immediate actions taken as a result of the incident:
List supplementary actions taken:
Enter the sequence of events from initial report and interviews:
Was a safe work procedure available?
Was a safe work procedure used?
Was a risk assessment conducted?
Were controls in place as per the Risk assessment / WMS?
Were appropriate tools and materials available?
Were they used?
Personnel were trained to conduct the work?
Work Activity Briefing (WAB) was conducted noting all hazards?
The task remained unchanged from original job?
Were change management principals used?
All equipment was in good working order?
Was the equipment used as designed?
Equipment is regularly serviced?
Were pre-start checks conducted and correct?
Personnel were appropriately trained to operate equipment?
SDS are available on site?
All labels and signs in place and easy to read?
Appropriate PPE is available?
PPE was worn correctly?
Weather conditions were not a factor of the incident?
Area was clean and tidy, poor housekeeper was not a factor?
Was it too hot or too cold?
Was it noisy?
Was lighting adequate?
Was fatigue evident?
Was alcohol or another impairment evident?
Was the task being rushed?
Were workers complacent?
Was poor vision a factor?
Were health issues a factor?
Workers were experienced and adequately supervised?
List any other contributing factors:
Enter investigation conclusions: