Incident Investigation

• Completed by:

• Bodily location:

  Select Head Face Neck Upper Body Back Abdomen Arms Hands Legs Feet Internal or Psychological Combinations or Multiple Locations

  • Head
  • Face
  • Neck
  • Upper Body
  • Back
  • Abdomen
  • Arms
  • Hands
  • Legs
  • Feet
  • Internal or Psychological
  • Combinations or Multiple Locations

• Mechanism:

  Select Being Hit by Moving Objects Biological Factors Body Stressing Chemicals and Other Substances Falls, Trips and Slips of a Person Heat, Electricity and Other Environmental Factors Hitting Objects with a Part of the Body Mental Stress Sound and Pressure Vehicle Incidents and Other

  • Being Hit by Moving Objects
  • Biological Factors
  • Body Stressing
  • Chemicals and Other Substances
  • Falls, Trips and Slips of a Person
  • Heat, Electricity and Other Environmental Factors
  • Hitting Objects with a Part of the Body
  • Mental Stress
  • Sound and Pressure
  • Vehicle Incidents and Other

• Agency:

  Select Animal, Human and Biological Chemicals and Chemical Agencies Environmental Agencies Machinery and Fixed Plant Materials and Substances Mobile Plant and Transport Non-powered Handtools Appliances and Equipment Other and Unspecified Agencies Powered Equipment, Tools and Appliances

  • Animal, Human and Biological
  • Chemicals and Chemical Agencies
  • Environmental Agencies
  • Machinery and Fixed Plant
  • Materials and Substances
  • Mobile Plant and Transport
  • Non-powered Handtools Appliances and Equipment
  • Other and Unspecified Agencies
  • Powered Equipment, Tools and Appliances

Worker Interview

• Speak with the injured worker and run through all of the questions below, recording each answer.

• Can you briefly describe what happened leading up to, during, and after the incident?

• Can you describe your physical and mental state leading up to the incident? For example, were you feeling tired, stressed, or distracted?

• Have you encountered similar situations or hazards before? If so, how were they addressed?

• Were there any unusual conditions or circumstances that you noticed before the incident occurred?

  Yes

  No

  N/A

• The unusual conditions or circumstances were:

• Were there any tools or equipment you were using?

• Were they functioning correctly?

  Yes

  No

  N/A

• Were there any tools or equipment you were using? Were they functioning correctly?

• Were you wearing the required Personal Protective Equipment (PPE)?

  Yes

  No

• Can you explain why?

• Have you been trained on the task you were performing?

  Yes

  No

• Was the training recent and clear?

• Was there any form of communication, instruction, or directive given before the task?

  Yes

  No

• Was it clear and understood?

• Were you aware of the risks associated with the task you were performing?

  Yes

  No

• Were you provided with any risk assessments or safety protocols related to it?

  Yes

  No

  N/A

• Were there any interruptions or unexpected changes in the task or environment before the incident?

  Yes

  No

• The interruptions or unexpected changes were:

• How do you think this incident could be prevented in the future?

• Is there anything else you'd like to add or feel it's important for us to know?

Description of Event Review

• Did the workers description of the incident and what happened align with the initial report?

  Yes

  No

  N/A

• Is the deviation serious or was it just general miscommunications in relaying information due to the stress of the situation?

  Yes

  No

  N/A

Inherent Risk Rating

• 

• Using the risk matrix, calculate the inherent risk (what were the potential likelihood and consequence if this incident was worse):

  Extreme

  High

  Medium

  Low

Causal Factors (PEEPO):

• Causal factors analysis is like being a detective after something goes wrong, looking at every angle - people, surroundings, tools, tasks, and the company setup - to find out the real reasons it happened and how to prevent it in the future. Thinking about the incident and all evidence available, select as many causal factors for each category.

• People (Personnel involved) factors include:

  Select Lack of training or inexperience Fatigue or lack of sleep Miscommunication or no communication Personal stress, distractions, or emotional disturbances Non-compliance with procedures or policies Incorrect or insufficient Personal Protective Equipment (PPE) usage Language barriers or cultural differences Physical impairments or health conditions Misjudgment or perception error Overconfidence or complacency

  • Lack of training or inexperience
  • Fatigue or lack of sleep
  • Miscommunication or no communication
  • Personal stress, distractions, or emotional disturbances
  • Non-compliance with procedures or policies
  • Incorrect or insufficient Personal Protective Equipment (PPE) usage
  • Language barriers or cultural differences
  • Physical impairments or health conditions
  • Misjudgment or perception error
  • Overconfidence or complacency

• Environment (Surroundings where the incident occurred) factors include:

  Select Poor lighting or visibility Excessive or disruptive noise Adverse weather conditions (rain, heat, wind, cold, etc.) Slip, trip, or fall hazards (e.g., wet floors, uneven surfaces) Confined or restricted space Unfamiliar worksite or location Presence of hazardous substances or chemicals Inadequate ventilation or presence of harmful fumes Workspace ergonomics (poorly designed workspaces) Wildlife or insect disruptions

  • Poor lighting or visibility
  • Excessive or disruptive noise
  • Adverse weather conditions (rain, heat, wind, cold, etc.)
  • Slip, trip, or fall hazards (e.g., wet floors, uneven surfaces)
  • Confined or restricted space
  • Unfamiliar worksite or location
  • Presence of hazardous substances or chemicals
  • Inadequate ventilation or presence of harmful fumes
  • Workspace ergonomics (poorly designed workspaces)
  • Wildlife or insect disruptions

• Equipment (Machinery or tools involved) factors include:

  Select Malfunction or breakdown Lack of maintenance or infrequent inspections Incorrect tool/equipment used for the task Missing, damaged, or faulty safety guards or features No user manual, outdated, or unclear operating instructions Inadequate equipment training provided Equipment age and wear Compatibility issues with other equipment

  • Malfunction or breakdown
  • Lack of maintenance or infrequent inspections
  • Incorrect tool/equipment used for the task
  • Missing, damaged, or faulty safety guards or features
  • No user manual, outdated, or unclear operating instructions
  • Inadequate equipment training provided
  • Equipment age and wear
  • Compatibility issues with other equipment

• Process (Task or procedure being carried out) factors include:

  Select Lack of clear, updated, or relevant procedures or protocols Complexity or novelty of the task Inadequate or outdated risk assessment Time pressure, rushing, or not allowed adequate breaks Interruptions or multi-tasking during a critical task Inadequate supervision, oversight, or unclear chain of command Lack of feedback mechanisms or reporting structure Unclear roles and responsibilities

  • Lack of clear, updated, or relevant procedures or protocols
  • Complexity or novelty of the task
  • Inadequate or outdated risk assessment
  • Time pressure, rushing, or not allowed adequate breaks
  • Interruptions or multi-tasking during a critical task
  • Inadequate supervision, oversight, or unclear chain of command
  • Lack of feedback mechanisms or reporting structure
  • Unclear roles and responsibilities

• Organization (Factors related to the company’s structure and culture) factors include:

  Select Inadequate or negative safety culture and values Poor communication channels or hierarchical barriers Lack of resources allocated to safety measures Inadequate incident reporting and response system Lack of regular, relevant safety training and updates Pressure to prioritize productivity, profit, or speed over safety Absence of a whistleblowing system or fear of retaliation Contractual or economic pressures affecting safety Organizational change or restructuring without adequate risk assessment

  • Inadequate or negative safety culture and values
  • Poor communication channels or hierarchical barriers
  • Lack of resources allocated to safety measures
  • Inadequate incident reporting and response system
  • Lack of regular, relevant safety training and updates
  • Pressure to prioritize productivity, profit, or speed over safety
  • Absence of a whistleblowing system or fear of retaliation
  • Contractual or economic pressures affecting safety
  • Organizational change or restructuring without adequate risk assessment

• 

Primary Cause

• What was the main reason or underlying factor that led to an incident, without which the incident would not have occurred?

Controls

• Please prioritize the following controls to address the identified risks.

• Can the hazard be completely removed or the task be stopped?

  Yes

  No

• Can a less hazardous material or different method be used?

  Yes

  No

• Can the hazard be isolated from people, either by physical barriers or by distance?

  Yes

  No

• Can barriers, guarding or equipment be used to reduce the risk?

  Yes

  No

• Can procedures or training be enhanced to manage the risk?

  Yes

  No

• What protective equipment or clothing can workers use as a last resort?

• What protective equipment or clothing can workers use as a last resort?