Executive Team Investigation Review

• Investigation No.

• ETIR Title

• Conducted on

  Date

• Prepared by

• Location
  Address

• Incident Location

• Job #:

• Date of occurrence

  Date

• Date Reported

  Date

• Reported by? Name, work location,phone number.

• Energy Solutions Employee?

  Yes

  No

  N/A

• Contractor?

  Yes

  No

  N/A

Type of Incident. Select all that apply.

• Lost Time Injury?

  Off

  On

• Medical Treatment injury?

  Off

  On

• First aid Injury?

  Off

  On

• Occupational Illness?

  Off

  On

• Environmental?

  Off

  On

• Fire or Explosion?

  Off

  On

• Equipment Failure?

  Off

  On

• Property Damage?

  Off

  On

• Material or Business Loss

  Off

  On

• Restricted Work Injury ?

  Off

  On

• Motor Vehicle Accident

  Off

  On

• Threats?

  Off

  On

• Other

Injury description (if applicable)

• What type of injury?

• What body part was injured?

• Was follow-up treatment required?

  Yes

  No

  N/A

Person(s) Involved

• Employee name(s)

Description

• Does the Investigation clearly describe how the incident occurred.

• Were Immediate actions taken appropriate?

  Yes

  No

  N/A

Analysis

• Investigation Team suitably experienced to conduct the investigation

  Yes

  No

  N/A

• Background Information contains detailed information on prior conditions

  Yes

  No

  N/A

• all people involved interviewed?

  Yes

  No

  N/A

• Environmental conditions suitably assessed?

  Yes

  No

  N/A

• Equipment / Plant /Tools identified and considered

  Yes

  No

  N/A

• Procedures in place and followed?

  Yes

  No

  N/A

• Procedures reviewed and found suitable or change identifed?

  Yes

  No

  N/A

• Organisational Factors identified and considered?

  Yes

  No

  N/A

• Task /Environmental conditions identified and considered?

  Yes

  No

  N/A

• Individual / Team actions identified and considered?

  Yes

  No

  N/A

• Absent / Failed defences identified and considered?

  Yes

  No

  N/A

• Conclusion identified and considered factual and suitable

  Yes

  No

  N/A

• Root cause identified and appropriate?

  Yes

  No

  N/A

Prevention

• Corrective action plan established?

  Yes

  No

  N/A

• Corrective action(s) identified suitable to prevent re ocurrence?

  Yes

  No

  N/A

• Recommendation identified and suitable to prevent reoccurrence?

  Yes

  No

  N/A

• All actions from action plan assigned to a person with a completion date

  Yes

  No

  N/A

• What action or recommendations have been implemented to prevent recurrence? When? And actioned by?

• Evidentiiary docs e.g. Licenses,qualifications, Incident photos etc included within the ICAM investigation?

  Yes

  No

  N/A

• Learnings shared with other sites?

  Yes

  No

  N/A

Conclusion

• ETIR Team comments and recommendations

• Add media

  Media

• ETIR Team Members:

  Sign