Information

  • Insert main photo

  • Document No.

  • Incident Investigation Report

  • Title

  • Conducted on

  • Lead Investigator

  • Location
  • Personnel

  • This document must not be copied

ICAM Investigation

Incident Type

  • Select Incident Types

  • List incident type

  • F0423 - Incident Schedule

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

  • Incident Level

Incident Date

  • Select date

Investigation Team

Distribution

Incident Detail

  • Injured Persons Name

  • Company

  • Medical Treatment

  • Description of damage

  • Total Incident Cost

  • Risk Rating

  • Environmental Impact

Incident Description

Executive Summary

Incident Timeline

    Critical Event
  • Event details

Photo Log

    Photo #
  • Insert photo

  • Brief desription

Witness statements

  • Insert witness statements

Sketches or diagrams

  • Draw diagrams of incident scene

Contributing Factors

Task / Environmental Conditions

  • Not in proper working order

  • Not suitable for the physical needs of the person

  • Not capable of performing the expected task

  • Not being properly maintained

  • Not safe by design

  • Not constructed without defect

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

  • Without the appropriate guards and controls

  • Equipped with necessary warning systems? Were they working

  • The lighting was inadequate

  • Noise or Vibration was a factor

  • Heat or cold was a factor

  • Personal protective equipment was not readily available

  • Path of vision was blocked

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

  • Work area was not clean and free of debris

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

  • Warning signs were not in place in designated areas

  • Protruding objects were in the workplace

  • Harmful amounts of contaminants in the air

Procedures or Work Method

  • The Standard Work Instruction was inaccurate

  • The Standard Work Instructions were not encouraged or reinforced

  • The best procedures were not being used for the process

  • Personal protective equipment was not being used property

Absent or failed defences

  • Defective

  • Not the correct on to use in the process

  • Inappropriately altered or changed in any way

  • Flammable

  • Potentially harmful

  • Damaged in storage

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

  • Giving off harmful fumes, odours, dusts etc.

Individual / Team Action

  • Have not received the necessary training

  • Do not know how to use the equipment

  • Do not know the hazards related to the job

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

  • Are influenced or pressured by peers

  • Are influenced by inadequate to inappropriate incentives

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

  • Are they injured, ill or fatigued

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

  • Are they angry, stressed etc

Organisational Failures - Basic Causes

  • Lack of Hazard Identification or Risk Assessment

  • Lack of training, skill or knowledge

  • Lack of Change Management

  • Production expectations in conflict with WHS best practices

  • Good housekeeping rules not enforced

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

  • Rules and Procedures not enforced appropriately

  • Legislative and company standards not being followed

  • Maintenance and Inspections program's were inadequate

Conclusions or Observations

Corrective and Preventative Actions

    Corrective Action
  • Corrective action details

To be actioned by

  • Full name

Expected Completion date

  • Select date

Investigation Review Checklist

  • Has the unsafe condition been corrected

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

  • Are the users satisfied with the changes

  • Has the work method been reviewed with all users

  • Is the work method readily available to the users

  • Do users require training

  • Has the ELT management team reviewed changes

Feedback & Approvals

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)

  • Comments

  • Supervisor
  • Supervisor

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

  • Director acceptance of findings and comments

  • Comments

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

  • Comments:

  • CEO acceptance of findings and comments

  • Comments

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

  • The report is confidential and subject to limited distribution.

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