Information
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Incident Description / Summary
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Project Name
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Location
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Incident Occurred on
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Prepared by
1. INVESTIGATIVE TEAM MEMBERS
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Names of investigative team
2. CLIENT NOTIFICATION
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Has the client been notified?
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Time and Date
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Person notified
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INFORM BECHTEL
3. INCIDENT DETAILS
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Date and time of incident
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Location of incident
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Incident
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Incident Level
- Report Only
- Low - First Aid/Minor Medical Treatment/ Minor Environmental Incident/Minor Property Damage
- Medium - Medically Treated Injury(MTI) / Medium Environmental Incident / Medium Property Damage
- High - Serious Injury / Fatality / Major Environmental Incident /Major Property Damage
- Extreme - Multiple Fatalities
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Incident type
- Environmental
- First Aid
- Lost Time Injury (LTI)
- Medically Treatment Injury (MTI)
- Property Damage
- Refused Care
- Report Only
- Restricted Work
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Person(s) involved
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Plant / Equipment involved
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Injuries / Damage sustained
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Damages cost estimate
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Sequence of events
4. EVIDENCE
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Photographs
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Enter drawings?
Drawing
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Drawing
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Enter statements?
Statement
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Statement
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Signature
5. 5 WHY
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Incident Details
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1. Why did the incident happen?
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Supporting data
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2. Why did 1 happen?
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Supporting data
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3. Why did 2 happen
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Supporting data
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4. Why did 3 happen?
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Supporting data
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5. (Optional) Why did 4 happen?
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Supporting data
6. ROOT CAUSE (What was the answer to the last question?)
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Enter root cause?
Root cause
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Root Cause
- Risk Assessment
- Procedure
- Design
- Quality Control
- Maintenance
- Human Factors
- Management
- Training
- Communication
- Environmental
- Other - List Below
7. RECOMMENDATIONS
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Enter recommendation?
Recommendation
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Recommendation
Corrective Actions
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Corrective Action 1
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Date to be completed by?
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To be completed by
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Evidence of Corrective Action
Signatures
Construction Manager
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Comments
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Date
OHS Manager
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Comments
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Date
Chief Operating Officer
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Comments
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Date
Site Manager
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Comments
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Date
Project Manager
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Comments
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Date
