Title Page
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INX Event Number
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Event Type
- Equipment Damage
- Production Loss
- Near Miss / Hit
- Procedure Breach
- Theft
- Environment
- Injury
- Community
- Fitness for Work
- Illness
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Conducted on
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Date of Event
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Date of Investigation
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Team Leader
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Team Members
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Location
PART 1: INCIDENT DETAILS
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Brief Description of Event
PART 2: TIMELINE
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Events Leading Up To The Incident
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Events At The Time Of The Incident
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Post Incident
PART 3: INVESTIGATION FINDINGS
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Absent or Failed Defences
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Select an absent or failed defence
- DF1 (Awareness - hazard identification)
- DF2 (Awareness - Communication)
- DF3 (Awareness - Competence / Knowledge)
- DF4 (Awareness - Supervision)
- DF5 (Awareness - Work Instruction / Procedures)
- DF6 (Detection - Visual Warning Systems)
- DF7 (Detection - Aural Warning Systems)
- DF8 (Detection - Speed / Movement Detectors)
- DF9 (Detection - Vigilance / Fatigue)
- DF10 (Detection - Gas / Substance)
- DF11 (Control and Recovery – procedures)
- DF12 (Control and Recovery – bypass valves / circuit)
- DF13 (Control and Recovery – emergency shutdown)
- DF14 (Protection and Containment – PPE)
- DF15 (Protection and Containment - fire fighting)
- DF16 (Protection and Containment – spill response)
- DF17 (Protection and Containment – bunding / barricade)
- DF18 (Escape and Rescue – safe access / egress)
- DF19 (Escape and Rescue – emergency planning / response)
- DF20 (Escape and Rescue – emergency communication)
- DF21 Other (Specify):
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Description
Individual / Team Actions
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Select a contributing individual or team action
- IT01 (Supervisory error or violation)
- IT02 (Operating authority error or violation)
- IT03 (Operating speed)
- IT04 (Equipment use error or violation)
- IT05 (PPE use error or violation)
- IT06 (Procedural compliance)
- IT07 (Change management error)
- IT08 (Equip/materials handling error or violation)
- IT09 (Horseplay/thrill seeking violation)
- IT10 (Hazard recognition/perception)
- IT11 (Hazard management error or violation)
- IT12 (Work method error or violation)
- IT13 (Occupational hygiene practices)
- IT14 Other (Specify):
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Description
Task / Environmental Conditions (Workplace)
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Select a contributing workplace factor that affected the task or environmental conditions
- TW01 (Task planning/preparation/manning)
- TW02 (Hazard analysis/JSA/Take 5)
- TW03 (Procedures - availability and suitability)
- TW04 (Permit to work - availability/suitability)
- TW05 (Abnormal operational situation or condition)
- TW06 (Tools/equip condition/availability)
- TW07 (Materials condition/availability)
- TW08 (Equipment integrity)
- TW09 (Housekeeping)
- TW10 (Weather conditions)
- TW11 (Congestion/restriction/access)
- TW12 (Routine/non routine task)
- TW13 (Fire and/or explosion hazard)
- TW14 (Lighting)
- TW15 (Equipment/material temperature/condition)
- TW16 (Noise)
- TW17 (Ventilation)
- TW18 (Gas, dust or fumes)
- TW19 (Radiation)
- TW20 (Chemical)
- TW21 (Wildlife)
- TW22 (Surface gradient/conditions)
- TW23 (Reduced/restricted visibility)
- TW24 Other (Specify):
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Description
Task / Environmental Conditions (Human)
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Select a contributing human factor that affected the task or environmental conditions
- HF01 (Complacency/motivation desensitisation to hazard)
- HF02 (Drugs/alcohol influence)
- HF03 (Familiarity with task)
- HF04 (Fatigue)
- HF05 (Situational awareness)
- HF06 (Time/productivity pressures)
- HF07 (Peer pressure/supervisory example)
- HF08 (Physical capabilities)
- HF09 (Mental capabilities)
- HF10 (Physical stress)
- HF11 (Mental stress)
- HF12 (Confidence level)
- HF13 (Secondary goals)
- HF14 (Personal issues )
- HF15 (Distraction/pre-occupation)
- HF16 (Experience/knowledge/skill for task)
- HF17 (Competency)
- HF18 (Behavioural beliefs (gains > risks))
- HF19 (Personality/attitude)
- HF20 (Poor/inadequate communications)
- HF21 (Poor shift patterns & overtime working )
- HF22(Passive tolerance of violations)
- HF23 (Perceived licence to bend rules)
- HF24 (Change of routine)
- HF25 (Reliance on undocumented knowledge)
- HF26 Other (Specify):
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Description
Organisational Factors
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Select a contributing organisational factor
- HW: Hardware
- TR: Training
- OR: Organisation
- CO: Communication
- IG: Incompatible Goals
- PR: Procedures
- MM: Maintenance Management
- DE: Design
- RM: Risk Management
- MC: Management of Change
- CM: Contractor Management
- OC: Organisational Culture
- RI: Regulatory Influence
- VM: Vehicle Management
- MS: Management Systems
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Description
PART 4: KEY LEARNINGS
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Identify the root causes
PART 5: SUPPORTING DOCUMENTS (Attachments)
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Photos
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Add media
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Written Statement
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Training Records
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Procedures
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Sketches
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Witness Statement
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Inspection Records
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Add media
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Other:
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Specify:
PART 6: CORRECTIVE ACTIONS
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Action
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Action:
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Action Responsibility:
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Due Date:
PART 7: REVIEW AND APPROVAL
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Department Manager
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Investigation Leader
