Incident/Injury Investigation

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location

  Select Alliance Cicero Commerce Corwith Hobart Houston LPC LPKC Memphis Oakland Portland San Bernardino SIG South Seattle St. Louis St. Paul Stockton Willow

  • Alliance
  • Cicero
  • Commerce
  • Corwith
  • Hobart
  • Houston
  • LPC
  • LPKC
  • Memphis
  • Oakland
  • Portland
  • San Bernardino
  • SIG
  • South Seattle
  • St. Louis
  • St. Paul
  • Stockton
  • Willow

• Incident/Injury Investigation Reporting:
  
  An incident usually refers to an unexpected event that could potentially cause injury or damage. The term incident is used in some situations to cover both an "accident" and "incident". It is argued that the word "accident" implies that the event was related to fate or chance. When the root cause is determined, it is usually found that many events were predictable and could have been prevented if the right actions were taken -- making the event not one of fate or chance (thus, the word incident is used). For simplicity, we will use the term incident to mean all of the above events.
  
  The form that follows is intended to be a general guide for ISS personnel or joint investigations. When incidents are investigated, the emphasis should be concentrated on finding the root cause of the incident rather than the investigation procedure itself so you can prevent it from happening again. The purpose is to find facts that can lead to actions, not to find fault. We must always look for deeper causes.
  
  Incidents that involve no injury or property damage should still be investigated to determine the hazards that should be corrected. The same principles apply to a quick inquiry of a minor incident and to the more formal investigation of a serious event.
  
  The incident investigation process involves the following steps:
  
  1. Report the incident occurrence to a designated person.
  2. Provide first aid and medical care to injured person(s) and prevent further injuries or damage if onsite when occurred.
  3. Investigate the incident
  4. Identify the causes
  5. Report the findings
  6. Develop a plan for corrective action
  7. Implement the plan
  8. Evaluate the effectiveness of the corrective action
  9. Make changes for continuous improvement
  
  As little time as possible should be lost between the moment of an incident or near miss and the beginning of the investigation. In this way, one is most likely to be able to observe the conditions as they were at the time, prevent disturbance of evidence, and identify witnesses. The tools that members of the investigating team may need (pencil, paper, camera, tape measure, etc.) should be immediately available so that no time is wasted.
  

Part I - General Information

• Name(s) of Involved

• Company(s)

• Job Titles(s)

• What shift?

• How long has the individual(s) been employed?

• Was medical attention sought?

  Yes

  No

  N/A

• What is/was the severity of the injuries?

Part II - Description of the Incident (Who - What - When - Where - Why)

• Comments

• Add media

  Media

• Media Comments

Part III - The Root Cause (What did the individual(s) do, or fail to do, that contributed to this incident/injury?)

• Root Cause:

• Contributing Factors:

• Did physical condition (hearing or eye defect, sickness, fatigue) cause or contribute to the incident/injury?

  Yes

  No

  N/A

• Comments

• Did the equipment or tool(s) used contribute to the incident/injury in any way?

  Yes

  No

  N/A

• Comments

Part IV - Corrective Actions Taken

• What is being done to prevent further incidents/injuries? (Be specific and avoid vague or meaningless details)

Part V - Final Review

• ISS Signature

  Sign

• Management Signature

  Sign

• Additional Comments