ESC - Incident Investigation Form Checklist

• 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:

Reference documentation:

• Procedure used?

• WMS used?

• Work activity briefing?

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

  Media

• Add drawing

  Drawing

Contributing Factors: Task / Procedural

• Was a safe work procedure available?

  Yes

  No

  N/A

• Was a safe work procedure used?

  Yes

  No

  N/A

• Was a risk assessment conducted?

  Yes

  No

  N/A

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

  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

• Work Activity Briefing (WAB) was conducted noting all hazards?

  Yes

  No

  N/A

• The task remained unchanged from original job?

  Yes

  No

  N/A

• Were change management principals used?

  Yes

  No

  N/A

Contributing Factors: Equipment / Substance

• All equipment was in good working order?

  Yes

  No

  N/A

• Was the equipment used as designed?

  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

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

  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?

  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 it noisy?

  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

• Was poor vision a factor?

  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