ICAM Investigation Report (example template)

• Insert main photo

• Document No.

• Incident Investigation Report

• Title

• Conducted on

  Date

• Lead Investigator

• Location
  Address

• Personnel

• This document must not be copied

Incident Type

• Select Incident Types

  Select Fatality Lost Time Injury Medical Treatment Near Miss Damage Other

  • Fatality
  • Lost Time Injury
  • Medical Treatment
  • Near Miss
  • Damage
  • Other

• List incident type

• F0423 - Incident Schedule

Incident Level (Refer to F0423). NOTE: Consider the potential not just the outcome.

• Incident Level

  Level 1 (Low)

  Level 2 (Moderate)

  Level 3 (High)

  Level 4 (Extreme)

Incident Date

• Select date

  Date

Investigation Team

Distribution

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

• Event details

  Date

Photo Log

Photo #

• Insert photo

  Media

• Brief desription

Witness statements

• Insert witness statements

  Media

Sketches or diagrams

• Draw diagrams of incident scene

  Drawing

Contributing Factors

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 WHS best practices

  Causal Factor

  N/A

• Good housekeeping rules not enforced

  Causal Factor

  N/A

• Program's not in place to encourage WHS 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

• Corrective action details

To be actioned by

• Full name

Expected Completion date

• Select date

  Date

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 ELT management team reviewed changes

  Yes

  No

  N/A

Supporting Documentation

Supporting document

• List details of additional supporting documentation and upload or attach documents to the final report

Significant Learnings for communication to the organisation

Report Sign-off

Involved Person

• Involved Person (s)

  Sign

• Comments

Supervisor

• Supervisor

  Sign

• Feedback to the involved person (s) Supervisor (s) and comments comments

• Director acceptance of findings and comments

  Sign

• Comments

• Senior Work Health & Safety Advisor acceptance of findings and comments

  Sign

• Comments:

• CEO acceptance of findings and comments

  Sign

• Comments

• This report has been prepared for the purpose of advancing safety.

• The report is confidential and subject to limited distribution.