INCIDENT INVESTIGATION - duplicate

• Site conducted

  Select

• Date of Incident:

  Date

• Incident Report Completed by:

• (SYSTEMS MANAGER USE ONLY) Status of Report:

  COMPLETED

  PENDING

• Incident / Event has been documented in the Incident Register

• What issues / actions are pending?

INVESTIGATION PLAN

• What are the immediate causes?

• What are the suspected root causes (prior to undertaking any investigation)?

• Are there any other noteworthy observations?

• Does this incident event require an ICAM investigation?

  Yes

  No
Investigation Team Members:

• Name:

• Position Title:

Investigation Objectives:

• Goal:

• Responsible Person:

• Investigation Scope (boundaries of the investigation):

• What date is the investigation expected to be completed by?

  Date

• Are there any constraints to meet the investigation timeframe?

PEEPO (People, Environment, Equipment, Procedure, Organisation )

People:

• Name:

• Involvement in Incident / Investigation

Environment:

• Location of Event:

• Has the scene been secured / preserved and photos / measurements taken?

  Yes

  Part

  No

  N/A

• Environmental Factors influencing the event: (consider weather, lighting, area set up, housekeeping, dust, water etc)

Equipment:

• Was plant or equipment involved in the incident / event?

  Yes

  No
Equipment Involved

• Type of Equipment:

• Were prestarts conducted for the plant / equipment involved? (if yes, attach as evidence)

  Yes

  Part

  No

  N/A

• Did the prestarts reveal any faults?

  Yes

  No

• Provide details:

• Equipment factors that may influence the event: (consider equipment selected for task / design / modifications / age / condition)

Procedures:

• Was there a procedure for the task?

  Yes

  No

  Part

• List the names of the procedures:

• Was there a risk assessment completed for the task?

  Yes

  No

• Were the hazards that resulted in the incident identified in either the procedure/s or risk assessment/s

  Yes

  Part

  No

  N/A

• What were the controls?

• Was the procedure or risk assessment followed for the task?

  Yes

  Part

  No

  N/A

• Specify the procedural / risk assessment step/s that weren't followed

Organisation:

• Were there previous related or similar incidents involving the team and / or persons involved in the event?

  Yes

  No
Previous Incident

• Specific details:

• What is the status of actions from previous incidents? (if applicable)

EVALUATE INFORMATION / ANALYSIS

• Contributing Factors:

• Root Cause:

• Additional Findings:

IDENTIFIED COURSES OF ACTION

Corrective Action

• Contributing Factor / Root Cause:

• Responsible Person:

• Due Date:

  Date

• Process to Communicate Investigation Findings:

  Toolbox Talks

  Email

  Newsletter

  Hub Meeting/s

• Date for Communication to be finalised:

  Date

• Responsible Person to Communicate Findings

• Reason for not doing a detailed investigation: