Date and time of incident:
Incident summary from report

Provide a summary of the incident:

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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
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Contributing Factors: Task / Procedural

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?

Contributing Factors: Equipment / Substance

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?

Contributing Factors: Environment / Behaviour

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?

Other Contributing factors:

List any other contributing factors:

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Enter investigation conclusions:


Enter recommendations:

Signature of investigating officer:
Signature of manager: