Incident Investegation Form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

Injured Person Details

• Name

• Role:

• Dealer Staff

• Contractor Company

• Visitor

• Public

Incident Facts:

• Date of Incident

• Time of Incident

• Date Reported

• Injury, if any (brief description)

• Treatment

• Ambulance

• Medical (Doctor)

• First Aid

• Hospital

• Nil

• Location

• Task

• Equipment Involved: Note: Remove from use until verified safe by competent person

• Brief Description of Incident

• Other Comments

Investigation

• Investigation Team

Root Cause Analysis

• Contributing Factors

• System factors

• Was there a risk assessment/JSA for the task?

• What informal and formal processes in place?

• Deviation from normal practice?

• Warning signs and information in place?

• Personal Factors

• What training/ instruction /supervision was provided?

• Level of person’s experience?

• Potential distractions?

• Adherence to workplace rules?

• Plant and Equipment Factors

• When was the last repair, alternation or maintenance? Seek records.

• Protective devices in place and well maintained?

• Were the tools being used for the correct purpose?

• Environment Factors

• Workplace design suited to current use?

• Current housekeeping standard? Check inspection records.

Root Causes and Action Plan

• Root Cause

• Countermeasure/Action

• Responsible Person

• Timing

• Entered onto Risk Register