HSE Investigation Report_Exus 2020

• Document No.

• Client

  Select

• Project

  Select

• Date of investigation report

  Date

• Prepared by

1.0 First Event/Incident Details

• 1.1 Date & Time of Incident

  Date
• 1.2 Location of Incident
  Address

• 1.3 Incident Priority?

  Urgent

  High

  Medium

  Low

  Trivial

• 1.4 Site / Project Name

• 1.5 Contractor

  Select

• Name of the Contractor

• 1.6 Employee, team, Subcontractor involved

• 1.7 Name of on-duty supervisor at time of incident?

• 1.8 Incident Type (select all that apply)

  Select Hazard Near-Miss Incident/Property damage Enviromental incident First Aids Recordable Injury Lost time injury Fatality Other

  • Hazard
  • Near-Miss
  • Incident/Property damage
  • Enviromental incident
  • First Aids
  • Recordable Injury
  • Lost time injury
  • Fatality
  • Other

• Please describe the type of incident

• Hazard Event; Source or situation with a potential to cause injury and ill health. Near Miss; An unplanned event which did not result in injury, illness, or damage – but had the potential to do so. Incident; Incident; An unplanned event which did not result in injury, illness, only a material damage. First Aids Incidents that only require first aid treatment. Recordable Injury Significant work-related injuries or illnesses diagnoses by a physician or other licensed health care professional, even if it does not result in death, days away from work. Lost time Injury All work-related injuries and illnesses that result in days away from work (More than 1 day)

• 1.9 Damage property

  Yes

  No

  N/A

• Describe the damage details and equipments/facilities involved

• 1.10 Has this person sustained an injury?

  Yes

  No

  N/A

• 1.10.1 Type of injury or illness? (select all that apply)

  Select Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & Spinal Cord Amputation Intracranial Other

  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & Spinal Cord
  • Amputation
  • Intracranial
  • Other

• Describe type of injury or illness

• 1.10.2 Parts of body affected? (select all that apply)

  Select

• Describe the body part affected

• 1.10.3 What kind of medical attention was administered?

  Select First Aid Doctor Consulted Hospital Ambulance Medical Attention Declined

  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

• 1.10.4 Will be injured person be absent from work more than one work day?

  Yes

  No

  N/A

• 1.10.4.1 Date of medical leave

  Date

• 1.10.4.2 Please detail medical attention

2.0 Describe What Happened

• 2.1 Describe what happened.

• Please be detailed but state only facts. The rest information or conlusion, in the next section "Detail reference information about the investigation "

• 2.2 What were the weather / environmental conditions at the time of the incident?

  Select Clear Cloudy Rain Snow Windy Heatwave Haze Other

  • Clear
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Heatwave
  • Haze
  • Other

• Describe the weather / environmental conditions at the time of the incident

• 2.3 Do you wish to include a timeline of events for this incident?

  Yes

  No

  N/A

Incident Timeline

• Build a timeline of key incident events below

Event

• Event Date / Time

  Date

• Event Description

3.0 Record Evidence and Information

• 3.1 Which of the following do you need to attach to this report to accuractly document this incident?

  Select Evidence Equipment Details Vehicle Details Damages Other Items

  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Evidence Log

• Please log all relevant evidence below

Evidence

• Evidence Description

• Photos of evidence (if applicable)

  Media

• Please detail any further information regarding this evidence (if applicable)

Vehicle Log

• Please log all relevant vehicle details below

Vehicle

• Vehicle; ;Mark and model

• Driver (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this vehicle (if applicable)

Damage Log

• Please log all relevant damage details below

Damage

• Damage description

• Photos of damage (if applicable)

  Media

• Please detail any further information regarding this damage (if applicable)

Other Items Log

• Please log all relevant details of other items below

Item

• Item description

• Photos of item (if applicable)

  Media

• Please detail any further information regarding this item (if applicable)

Equipment Log

• Please log all relevant equipment details below

Equipment

• Equipment Mark and model

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this equipment (if applicable)

4.0 People involved

• Please document all people involved in this incident, including yourself (the person reporting the incident)

Person

• Full Name

• What is this person's relation to the incident? (select all that apply)

  Select Reporter of incident Injured person Witness Primary person involved Secondary Involvement On-duty supervisor Investigator Suspect Other

  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Suspect
  • Other

• Describe this person's relation to the incident

• Please describe this person's involvement with the incident, including all relevant information

• Does this person wish to make a preliminary statement?

  Yes

  No

  N/A

Preliminary Statement

• Statement regarding incident

• Person Signature

  Sign

5.0 Inmediate corrective actions

• Please add any inmediate corrective actions performed after the event

• 5.1 Inmediate corrective actions performed with regard to this incident?

  Select
Describe the Inmediate corrective action implemented

• Describe the inmmediate corrective action performed

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

6.0 Ivestigation of Event. Root Cause Analysis/Contributing Factors

• 6.1 Detail reference information about the investigation

• Please detail in this item, the different conclussions or reference information about the investigation

• 6.2 What were the contributing factors to this incident occurring? (select all that apply)

  Select

• Add notes to describe the different factors selected

• 6.3 Define the types of the Root Causes

  Select
Root Causes

• Describe the root cause of the event

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

• 6.4 How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

7.0 Corrective/Preventive Actions

Corrective/Preventive action

• Please add any corrective actions to the appropriate questions above before completing this incident report .The preventive and corrective actions, must be implemented as actions to perform and schedule in this report

• Describe the Corrective/Preventive action performed

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

Sign Off

• Name of investigation author

  Select

• Name & Signature of Reporter

  Sign