ICAM Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Incident Date

• Select date

  Date

Investigation Team

Distribution

Approved by

Incident Detail

• Injured Persons Name

  Verified

  Approx.

• Company

  Verified

  Approx.

• Medical Treatment

  Verified

  Approx.

• Description of damage

  Verified

  Approx.

• Total Incident Cost

  Verified

  Approx.

• Risk Rating

  Verified

  Approx.

• Environmental Impact

  Verified

  Approx.

Incident Description

Executive Summary

Incident Timeline

• Critical Event 1

  Date

• Critical Event 2

  Date

• Critical Event 3

  Date

• Critical Event 4

  Date

• Critical Event 5

  Date

• Critical Event 6

  Date

• Critical Event 7

  Date

• Critical Event 8

  Date

• Critical Event 9

  Date

Witness statements

• Add media

  Media

Sketches or diagrams

• Add drawing

  Drawing

• Add media

  Media

Task / Environmental Conditions

• Not in proper working order

  Causal Factor

  N/A

• Not suitable for the physical needs of the person

  Causal Factor

  N/A

• Not capable of performing the expected task

  Causal Factor

  N/A

• Not being properly maintained

  Causal Factor

  N/A

• Not safe by design

  Causal Factor

  N/A

• Not constructed without defect

  Causal Factor

  N/A

• Defective due to excessive use, misuse and/or abuse

  Causal Factor

  N/A

• Without the appropriate guards and controls

  Causal Factor

  N/A

• Equipped with necessary warning systems? Were they working

  Causal Factor

  N/A

• The lighting was inadequate

  Causal Factor

  N/A

• Noise or Vibration was a factor

  Causal Factor

  N/A

• Heat or cold was a factor

  Causal Factor

  N/A

• Personal protective equipment was not readily available

  Causal Factor

  N/A

• Path of vision was blocked

  Causal Factor

  N/A

• Equipment and materials were not stored/installed in the designated area

  Causal Factor

  N/A

• Work area was not clean and free of debris

  Causal Factor

  N/A

• The work station was not designed to fit the needs of the individual

  Causal Factor

  N/A

• Warning signs were not in place in designated areas

  Causal Factor

  N/A

• Protruding objects were in the workplace

  Causal Factor

  N/A

• Harmful amounts of contaminants in the air

  Causal Factor

  N/A

Procedures or Work Method

• The Standard Work Instruction was inaccurate

  Causal Factor

  N/A

• The Standard Work Instructions were not encouraged or reinforced

  Causal Factor

  N/A

• The best procedures were not being used for the process

  Causal Factor

  N/A

• Personal protective equipment was not being used property

  Causal Factor

  N/A

Absent or failed defences

• Defective

  Causal Factor

  N/A

• Not the correct on to use in the process

  Causal Factor

  N/A

• Inappropriately altered or changed in any way

  Causal Factor

  N/A

• Flammable

  Causal Factor

  N/A

• Potentially harmful

  Causal Factor

  N/A

• Damaged in storage

  Causal Factor

  N/A

• In a changed state (eg. liquid to vapour)

  Causal Factor

  N/A

• Giving off harmful fumes, odours, dusts etc.

  Causal Factor

  N/A

Individual / Team Action

• Have not received the necessary training

  Causal Factor

  N/A

• Do not know how to use the equipment

  Causal Factor

  N/A

• Do not know the hazards related to the job

  Causal Factor

  N/A

• Are not confident in their ability to complete the task properly

  Causal Factor

  N/A

• Are influenced or pressured by peers

  Causal Factor

  N/A

• Are influenced by inadequate to inappropriate incentives

  Causal Factor

  N/A

• Trying to save time or effort, avoid discomfort or attract attention

  Causal Factor

  N/A

• Are they injured, ill or fatigued

  Causal Factor

  N/A

• Are they some what distracted (mind on other things)

  Causal Factor

  N/A

• Are they angry, stressed etc

  Causal Factor

  N/A

Organisational Failures - Basic Causes

• Lack of Hazard Identification or Risk Assessment

  Causal Factor

  N/A

• Lack of training, skill or knowledge

  Causal Factor

  N/A

• Lack of Change Management

  Causal Factor

  N/A

• Production expectations in conflict with HSET best practices

  Causal Factor

  N/A

• Good housekeeping rules not enforced

  Causal Factor

  N/A

• Program's not in place to encourage HSET procedures and practices

  Causal Factor

  N/A

• Rules and Procedures not enforced appropriately

  Causal Factor

  N/A

• Legislative and company standards not being followed

  Causal Factor

  N/A

• Maintenance and Inspections program's were inadequate

  Causal Factor

  N/A

Conclusions or Observations

Corrective and Preventative Actions

Corrective Action 1

To be actioned by

Expected Completion date

• Select date

  Date

Corrective Action 2

To be actioned by

Expected completion date

• Select date

  Date

Corrective Action 3

To be actioned by

Completion date

• Select date

  Date

Correction Action 4

To be a actioned by

Completion date

• Select date

  Date

Corrective Action 5

To be actioned by

Investigation Review Checklist

• Has the unsafe condition been corrected

  Yes

  No

  N/A

• Has the unsafe practice been corrected (procedure people follow)

  Yes

  No

  N/A

• Are the users satisfied with the changes

  Yes

  No

  N/A

• Has the work method been reviewed with all users

  Yes

  No

  N/A

• Is the work method readily available to the users

  Yes

  No

  N/A

• Do users require training

  Yes

  No

  N/A

• Has the CSI management team reviewed changes

  Yes

  No

  N/A