Incident Investigation

Title Page

Site conducted
Date of Investigation
Completed By
Location
Incident Type
Injury Classification
- Lost Time Injury (1 or more full work days off)
- Medical Treatment Injury
- First Aid Injury
Type of Shift
Shift Length
Team Member

Investigation

Reason for Statement
Worker Statement
Worker Name
What task was being performed at the time of the incident?
What happened? (e.g. ‘worker tripped over box’ or ‘forklift hit wall’)
Was any damage sustained to plant and equipment?
Description of the damage and type of damage.
Was there any impact or damage to the environment?
Description of the impact or damage and type of impact.
Problem
Why?
Why?
Why?
Why?
Why?

ICAM (Contributing Factor Analysis)

Were there any absent or failed defences?
Select all that apply from the list
- Hazard identification
- Communication
- Competence / knowledge
- Supervision
- Work instruction
- Visual warning systems
- Auditory warning systems
- Speed / movement detectors
- Vigilance / fatigue
- Gas / substance detection
- Procedures
- Bypass valves / circuits
- Emergency shutdown
- PPE / clothing
- Firefighting equipment
- Spill response
- Bunding barricading / exclusion zones
- Fencing / guarding
- Safe access / egress
- Emergency planning / response
- Other
Describe other absent or failed defences
Did individual or team actions contribute to the event?
Select all that apply from the list
- Supervisory error or issue
- Work authority error
- Operating speed
- Equipment use error
- PPE use error
- Procedural compliance
- Change management error
- Equipment / materials handling error
- Horseplay / thrill seeking behaviour
- Hazard recognition / perception
- Hazard management error
- Work method error
- Occupational hygiene
- Physical fitness for work
- Psychological fitness for work
- Critical Risk Control error
- Other
Describe other individual or team actions
Did task / environmental conditions in the workplace contribute to the event?
- Yes
- No
Select all that apply from the list
- Task planning / preparation / resourcing
- Hazard analysis / risk assessment
- Availability / suitability of work procedures
- Abnormal operation situation
- Availability / condition of equipment or tools
- Availability / suitability of materials
- Equipment integrity
- Housekeeping
- Weather conditions
- Congestion / restricted access
- Routine / non-routine task
- Fire / explosion hazard
- Lighting
- Condition of equipment / materials temperature
- Noise
- Ventilation
- Gas, dust, or fumes
- Radiation
- Chemical
- Wildlife
- Surface / ground condition
- Reduced / restricted visibility
- Routine / non-routine task
- Other
Describe the task / environmental conditions
Did the task / environmental conditions from human factors contribute to the event?
Select all that apply from the list
- Complacency
- Drugs / alcohol
- Familiarity with task
- Fatigue
- Situational awareness
- Time / productivity pressure
- Physical capabilities
- Mental capabilities
- Confidence level
- Personal issues
- Distraction / pre-occupation
- Knowledge / experience in task
- Competency
- Personality / attitude
- Change of routine
- Reliance on undocumented knowledge
- Other
Describe the other human factors
Organisational Factors
Select all that apply from the list
- Hardware
- Training
- Organisation
- Communication
- Incompatible goals
- Procedures
- Maintenance management
- Design
- Risk management
- Management of change
- Contractor management
- Organisational culture
- Regulatory influence
- Organisational learning
- Plant / vehicle management
- Management systems
- Other
Describe the other organisational factors

Root Cause and Key Findings

What was the Root Cause? (The root cause is the one factor identified that if changed would have prevented the incident from occurring.)
What are the Key Findings?