Incident Investigation Form

Title of Inspection

• Incident Type

  Select Unsafe Condition Unsafe Act Near Miss Hi-Potential First Aid Recordable Property Damage

  • Unsafe Condition
  • Unsafe Act
  • Near Miss
  • Hi-Potential
  • First Aid
  • Recordable
  • Property Damage

• Affected Employee:

• Affected Employee:

• Affected Employee:

• Condition and Location:

• Behavior Observed:

• Employee Name:

• Condition and Location

• Please select the type of incident:

  Select Unsafe Condition Unsafe Act Near Miss Hi-potential First Aid Property Damage Recordable 3rd Party Property Damage

  • Unsafe Condition
  • Unsafe Act
  • Near Miss
  • Hi-potential
  • First Aid
  • Property Damage
  • Recordable
  • 3rd Party Property Damage

• Department

  Select Production Single Serve Maintenance Sanitation Warehouse Quality Other

  • Production
  • Single Serve
  • Maintenance
  • Sanitation
  • Warehouse
  • Quality
  • Other

• Process Area

  Bottling

  Bulk

  Main Kitchen

• Process Area

  DNS/SS Kitchen

  SSK/RS

• Describe Location

• Employee Name

• Date and Time of Incident

  Date

• Date Reported

  Date

• Shift

  1st

  2nd

  3rd

• Time Employee Began Work

  Date

• Employees usual job title

• Job at time of incident

• Length of time on the job before the incident had occurred

  In Training

  <1 Year

  >1 Year

• Describe in detail how the incident occured:

• Add pictures from incident here:

  Media

• Describe the work in progress (task) when the incident occurred

• Did anyone witness the incident?

  Yes

  No

• Who?

• Were statements recorded at the Nurse's station?

  Yes

  No

• Potential result of an incident

  Select Other Fall from elevation Fall, same level Slip Trip Struck against object Struck by object Caught in, under, between Overextension/Strain Motor vehicle/Forklift

  • Other
  • Fall from elevation
  • Fall, same level
  • Slip
  • Trip
  • Struck against object
  • Struck by object
  • Caught in, under, between
  • Overextension/Strain
  • Motor vehicle/Forklift

• Potentially contacted with/contacted by

  Select Chemicals Electricity Temperature Extremes Equipment Noise Radiation Insect Bite Glass Other Not Applicable

  • Chemicals
  • Electricity
  • Temperature Extremes
  • Equipment
  • Noise
  • Radiation
  • Insect Bite
  • Glass
  • Other
  • Not Applicable

• Reference: Complete List of all Causal Factors

  

• Causal Factor(s)

  Select Employee Supervision Equipment/Materials Other

  • Employee
  • Supervision
  • Equipment/Materials
  • Other

• Employee

  Select Physical Limitations Deficient in skill/ability Drugs/alcohol Lack of alertness Failure to follow written procedure Confined space entry LOTO Failure to follow oral instructions Failure to use PPE Operating without authority Taking an at risk position At risk speed (shortcut) Improper use of tool/equipment/material Use of incorrect tool/equipment/material Improper manual handling

  • Physical Limitations
  • Deficient in skill/ability
  • Drugs/alcohol
  • Lack of alertness
  • Failure to follow written procedure
  • Confined space entry
  • LOTO
  • Failure to follow oral instructions
  • Failure to use PPE
  • Operating without authority
  • Taking an at risk position
  • At risk speed (shortcut)
  • Improper use of tool/equipment/material
  • Use of incorrect tool/equipment/material
  • Improper manual handling

• Supervision

  Select Incorrect/incomplete procedures/instructions Rules/procedures not enforced Inadequate training of employee(s) Proper tools/equipment not provided Deficient storage/handling practices Inadequate housekeeping Rush by supervisor

  • Incorrect/incomplete procedures/instructions
  • Rules/procedures not enforced
  • Inadequate training of employee(s)
  • Proper tools/equipment not provided
  • Deficient storage/handling practices
  • Inadequate housekeeping
  • Rush by supervisor

• Equipment/Materials

  Select Defective equipment/tools/materials Inadequate or missing guards Inadequate or bypassed safety devices Inadequate maintenance/equipment/inspection Inadequate lighting Inadequate ventilation Inadequate design/layout (congestion) Inadequate fabrication/installation

  • Defective equipment/tools/materials
  • Inadequate or missing guards
  • Inadequate or bypassed safety devices
  • Inadequate maintenance/equipment/inspection
  • Inadequate lighting
  • Inadequate ventilation
  • Inadequate design/layout (congestion)
  • Inadequate fabrication/installation

• Other

  Select Horseplay/distraction by fellow employee Error by fellow employee Equipment/material/action of 3rd party Upset conditions Exposure to chemical/physical/biological agents Weather (rain/snow/ice/wind) Company sponsored activity Glass Other

  • Horseplay/distraction by fellow employee
  • Error by fellow employee
  • Equipment/material/action of 3rd party
  • Upset conditions
  • Exposure to chemical/physical/biological agents
  • Weather (rain/snow/ice/wind)
  • Company sponsored activity
  • Glass
  • Other

• Basic Cause(s)

  Select Lack of knowledge Not enforcing proper policies Engineering Inadequate PPE Purchasing inadequate/inferior equipment Lack of accountability Improper methods Inadequate inspection/maintenance

  • Lack of knowledge
  • Not enforcing proper policies
  • Engineering
  • Inadequate PPE
  • Purchasing inadequate/inferior equipment
  • Lack of accountability
  • Improper methods
  • Inadequate inspection/maintenance

• Immediate fix

5 Why (Root Cause)

• 1. Why did the incident happen?

• 2. Why did 1 happen?

• 3. Why did 2 happen

• 4. Why did 3 happen?

• 5. Why did 4 happen?

Corrective Actions

• Do the documented practices and assessments adequately cover the situation to prevent re-occurrence?

  Yes

  No

• If no, develop a corrective action

• Is the incident recordable and behavioral?

  Yes

  No

• If yes, develop a corrective action

• Is this incident a re-occurrence?

  Yes

  No

• If yes, develop a corrective action to address the re-occurrence and learn from what did not work last time

• Supervisor Corrective Action #1

• Responsible Person

• Target Date

  Date

• Supervisor Corrective Action #2

• Responsible Person

• Target Date

  Date

• Supervisor Corrective Action #3

• Responsible Person

• Target Date

  Date

• Employee Signature

  Sign

• Supervisor Signature

  Sign

• Department Manager

  Sign

• ORM Manager

  Sign

• Department

  Select Production Single Serve Maintenance Sanitation Warehouse Quality Other

  • Production
  • Single Serve
  • Maintenance
  • Sanitation
  • Warehouse
  • Quality
  • Other

• Process Area

  Bottling

  Bulk

  Main Kitchen

• Process Area

  DNS/SS Kitchen

  SSK/RS

• Describe Location

• Employee Name

• Date and Time of Incident

  Date

• Date Reported

  Date

• Shift

  1st

  2nd

  3rd

• Time Employee Began Work

  Date

• Employees usual job title

• Job at time of incident

• Length of time on the job before the incident had occurred

  In Training

  <1 Year

  >1 Year

• Describe in detail how the incident occured:

• Add pictures from incident here:

  Media

• Describe the work in progress (task) when the incident occurred

• Did anyone witness the incident?

  Yes

  No

• Who?

• Were statements recorded at the Nurse's station?

  Yes

  No

• Incident Type

  Select Caught in, under, between Contact by Contact with Fall from elevation Fall, same level Motor vehicle / PIT Struck against object Struck by object Other Slip Trip Overexertion / strain

  • Caught in, under, between
  • Contact by
  • Contact with
  • Fall from elevation
  • Fall, same level
  • Motor vehicle / PIT
  • Struck against object
  • Struck by object
  • Other
  • Slip
  • Trip
  • Overexertion / strain

• Contacted With/Contacted By

  Select Chemicals Electricity Temperature Extremes Equipment Noise Radiation Insect Bite Glass Other Not Applicable

  • Chemicals
  • Electricity
  • Temperature Extremes
  • Equipment
  • Noise
  • Radiation
  • Insect Bite
  • Glass
  • Other
  • Not Applicable

• Right or Left Side of Body?

  Select Right Left

  • Right
  • Left

• Right - Body Part Affected

  Select Head Eye(s) Ear(s) Face Neck Trunk/Torso Shoulders Chest Back/Spine Abdomen/groin Hip Upper Extremities Upper Arm Elbow Forearm Wrist Hand Finger(s) Lower Extremities Thigh Knee Skin/Calf Ankle Foot Toe(s) Body systems Circulatory Respiratory Other

  • Head
  • Eye(s)
  • Ear(s)
  • Face
  • Neck
  • Trunk/Torso
  • Shoulders
  • Chest
  • Back/Spine
  • Abdomen/groin
  • Hip
  • Upper Extremities
  • Upper Arm
  • Elbow
  • Forearm
  • Wrist
  • Hand
  • Finger(s)
  • Lower Extremities
  • Thigh
  • Knee
  • Skin/Calf
  • Ankle
  • Foot
  • Toe(s)
  • Body systems
  • Circulatory
  • Respiratory
  • Other

• Left - Body Part Affected

  Select Head Eye(s) Ear(s) Face Neck Trunk/Torso Shoulders Chest Back/Spine Abdomen/groin Hip Upper Extremities Upper Arm Elbow Forearm Wrist Hand Finger(s) Lower Extremities Thigh Knee Skin/Calf Ankle Foot Toe(s) Body systems Circulatory Respiratory Other

  • Head
  • Eye(s)
  • Ear(s)
  • Face
  • Neck
  • Trunk/Torso
  • Shoulders
  • Chest
  • Back/Spine
  • Abdomen/groin
  • Hip
  • Upper Extremities
  • Upper Arm
  • Elbow
  • Forearm
  • Wrist
  • Hand
  • Finger(s)
  • Lower Extremities
  • Thigh
  • Knee
  • Skin/Calf
  • Ankle
  • Foot
  • Toe(s)
  • Body systems
  • Circulatory
  • Respiratory
  • Other

• Nature of Injury

  Select Amputation Fracture/dislocate/crush Cut/scrape/puncture/sting Bruise/contusion Foreign object Irritation Hernia/rupture Avulsion Sprain/Strain Burn-chemical Burn-thermal/electrical Heat Stress/sunstroke Suffocate/asphyxiate (lack of oxygen) Concussion/unconsciousness Poisoning - Acute

  • Amputation
  • Fracture/dislocate/crush
  • Cut/scrape/puncture/sting
  • Bruise/contusion
  • Foreign object
  • Irritation
  • Hernia/rupture
  • Avulsion
  • Sprain/Strain
  • Burn-chemical
  • Burn-thermal/electrical
  • Heat Stress/sunstroke
  • Suffocate/asphyxiate (lack of oxygen)
  • Concussion/unconsciousness
  • Poisoning - Acute

• Nature of Illness

  Select Skin disease or disorder Dust disease of the lung(s) Respiratory (toxic agents) Poisoning (chronic) Physical Agents (radiation, etc.) Repeated Trauma (noise, CTDs, etc.) Other Illness Not Applicable

  • Skin disease or disorder
  • Dust disease of the lung(s)
  • Respiratory (toxic agents)
  • Poisoning (chronic)
  • Physical Agents (radiation, etc.)
  • Repeated Trauma (noise, CTDs, etc.)
  • Other Illness
  • Not Applicable

• Reference: Complete List of all Causal Factors

  

• Causal Factor(s)

  Select Employee Supervision Equipment/Materials Other

  • Employee
  • Supervision
  • Equipment/Materials
  • Other

• Employee

  Select Physical Limitations Deficient in skill/ability Drugs/alcohol Lack of alertness Failure to follow written procedure Confined space entry LOTO Failure to follow oral instructions Failure to use PPE Operating without authority Taking an at risk position At risk speed (shortcut) Improper use of tool/equipment/material Use of incorrect tool/equipment/material Improper manual handling

  • Physical Limitations
  • Deficient in skill/ability
  • Drugs/alcohol
  • Lack of alertness
  • Failure to follow written procedure
  • Confined space entry
  • LOTO
  • Failure to follow oral instructions
  • Failure to use PPE
  • Operating without authority
  • Taking an at risk position
  • At risk speed (shortcut)
  • Improper use of tool/equipment/material
  • Use of incorrect tool/equipment/material
  • Improper manual handling

• Supervision

  Select Incorrect/incomplete procedures/instructions Rules/procedures not enforced Inadequate training of employee(s) Proper tools/equipment not provided Deficient storage/handling practices Inadequate housekeeping Rush by supervisor

  • Incorrect/incomplete procedures/instructions
  • Rules/procedures not enforced
  • Inadequate training of employee(s)
  • Proper tools/equipment not provided
  • Deficient storage/handling practices
  • Inadequate housekeeping
  • Rush by supervisor

• Equipment/Materials

  Select Defective equipment/tools/materials Inadequate or missing guards Inadequate or bypassed safety devices Inadequate maintenance/equipment/inspection Inadequate lighting Inadequate ventilation Inadequate design/layout (congestion) Inadequate fabrication/installation

  • Defective equipment/tools/materials
  • Inadequate or missing guards
  • Inadequate or bypassed safety devices
  • Inadequate maintenance/equipment/inspection
  • Inadequate lighting
  • Inadequate ventilation
  • Inadequate design/layout (congestion)
  • Inadequate fabrication/installation

• Other

  Select Horseplay/distraction by fellow employee Error by fellow employee Equipment/material/action of 3rd party Upset conditions Exposure to chemical/physical/biological agents Weather (rain/snow/ice/wind) Company sponsored activity Glass Other

  • Horseplay/distraction by fellow employee
  • Error by fellow employee
  • Equipment/material/action of 3rd party
  • Upset conditions
  • Exposure to chemical/physical/biological agents
  • Weather (rain/snow/ice/wind)
  • Company sponsored activity
  • Glass
  • Other

• Basic Cause(s)

  Select Lack of knowledge Not enforcing proper policies Engineering Inadequate PPE Purchasing inadequate/inferior equipment Lack of accountability Improper methods Inadequate inspection/maintenance

  • Lack of knowledge
  • Not enforcing proper policies
  • Engineering
  • Inadequate PPE
  • Purchasing inadequate/inferior equipment
  • Lack of accountability
  • Improper methods
  • Inadequate inspection/maintenance

• Immediate fix

5 Why (Root Cause)

• 1. Why did the incident happen?

• 2. Why did 1 happen?

• 3. Why did 2 happen

• 4. Why did 3 happen?

• 5. Why did 4 happen?

Corrective Actions

• Do the documented practices and assessments adequately cover the situation to prevent re-occurrence?

  Yes

  No

• If no, develop a corrective action

• Is the incident recordable and behavioral?

  Yes

  No

• If yes, develop a corrective action

• Is this incident a re-occurrence?

  Yes

  No

• If yes, develop a corrective action to address the re-occurrence and learn from what did not work last time

• Supervisor Corrective Action #1

• Responsible Person

• Target Date

  Date

• Supervisor Corrective Action #2

• Responsible Person

• Target Date

  Date

• Supervisor Corrective Action #3

• Responsible Person

• Target Date

  Date

• Employee Signature

  Sign

• Supervisor Signature

  Sign

• Department Manager

  Sign

• ORM Manager

  Sign

• Department

  Select Production Single Serve Maintenance Sanitation Warehouse Quality Other

  • Production
  • Single Serve
  • Maintenance
  • Sanitation
  • Warehouse
  • Quality
  • Other

• Process Area

  Bottling

  Bulk

  Main Kitchen

• Process Area

  DNS/SS Kitchen

  SSK/RS

• Describe Location

• Employee Name

• Date and Time of Incident

  Date

• Date Reported

  Date

• Shift

  1st

  2nd

  3rd

• Time Employee Began Work

  Date

• Employees usual job title

• Job at time of incident

• Length of time on the job before the incident had occurred

  In Training

  <1 Year

  >1 Year

• OSHA Class

  Select Other Recordable Injury Job Transfer or Restriction of Work Days Away From Work Fatality Occupational Illness

  • Other Recordable Injury
  • Job Transfer or Restriction of Work
  • Days Away From Work
  • Fatality
  • Occupational Illness

• Describe in detail how the incident occurred:

• Add pictures from incident here:

  Media

• Describe the work in progress (task) when the incident occurred

• Did anyone witness the incident?

  Yes

  No

• Who?

• Were statements recorded at the Nurse's station?

  Yes

  No

• Incident Type

  Select Caught in, under, between Contact by Contact with Fall from elevation Fall, same level Motor vehicle / PIT Struck against object Struck by object Other Slip Trip Overexertion / strain

  • Caught in, under, between
  • Contact by
  • Contact with
  • Fall from elevation
  • Fall, same level
  • Motor vehicle / PIT
  • Struck against object
  • Struck by object
  • Other
  • Slip
  • Trip
  • Overexertion / strain

• Contacted With/Contacted By

  Select Chemicals Electricity Temperature Extremes Equipment Noise Radiation Insect Bite Glass Other Not Applicable

  • Chemicals
  • Electricity
  • Temperature Extremes
  • Equipment
  • Noise
  • Radiation
  • Insect Bite
  • Glass
  • Other
  • Not Applicable

• Description of Injury/Illness

  Select Medical Only Lost Time-Restricted Work Lost Time-Away From Work Fatality

  • Medical Only
  • Lost Time-Restricted Work
  • Lost Time-Away From Work
  • Fatality

• Right or Left Side of Body?

  Select Right Left

  • Right
  • Left

• Right - Body Part Affected

  Select Head Eye(s) Ear(s) Face Neck Trunk/Torso Shoulders Chest Back/Spine Abdomen/groin Hip Upper Extremities Upper Arm Elbow Forearm Wrist Hand Finger(s) Lower Extremities Thigh Knee Skin/Calf Ankle Foot Toe(s) Body systems Circulatory Respiratory Other

  • Head
  • Eye(s)
  • Ear(s)
  • Face
  • Neck
  • Trunk/Torso
  • Shoulders
  • Chest
  • Back/Spine
  • Abdomen/groin
  • Hip
  • Upper Extremities
  • Upper Arm
  • Elbow
  • Forearm
  • Wrist
  • Hand
  • Finger(s)
  • Lower Extremities
  • Thigh
  • Knee
  • Skin/Calf
  • Ankle
  • Foot
  • Toe(s)
  • Body systems
  • Circulatory
  • Respiratory
  • Other

• Left - Body Part Affected

  Select Head Eye(s) Ear(s) Face Neck Trunk/Torso Shoulders Chest Back/Spine Abdomen/groin Hip Upper Extremities Upper Arm Elbow Forearm Wrist Hand Finger(s) Lower Extremities Thigh Knee Skin/Calf Ankle Foot Toe(s) Body systems Circulatory Respiratory Other

  • Head
  • Eye(s)
  • Ear(s)
  • Face
  • Neck
  • Trunk/Torso
  • Shoulders
  • Chest
  • Back/Spine
  • Abdomen/groin
  • Hip
  • Upper Extremities
  • Upper Arm
  • Elbow
  • Forearm
  • Wrist
  • Hand
  • Finger(s)
  • Lower Extremities
  • Thigh
  • Knee
  • Skin/Calf
  • Ankle
  • Foot
  • Toe(s)
  • Body systems
  • Circulatory
  • Respiratory
  • Other

• Nature of Injury

  Select Amputation Fracture/dislocate/crush Cut/scrape/puncture/sting Bruise/contusion Foreign object Irritation Hernia/rupture Avulsion Sprain/Strain Burn-chemical Burn-thermal/electrical Heat Stress/sunstroke Suffocate/asphyxiate (lack of oxygen) Concussion/unconsciousness Poisoning - Acute

  • Amputation
  • Fracture/dislocate/crush
  • Cut/scrape/puncture/sting
  • Bruise/contusion
  • Foreign object
  • Irritation
  • Hernia/rupture
  • Avulsion
  • Sprain/Strain
  • Burn-chemical
  • Burn-thermal/electrical
  • Heat Stress/sunstroke
  • Suffocate/asphyxiate (lack of oxygen)
  • Concussion/unconsciousness
  • Poisoning - Acute

• Nature of Illness

  Select Skin disease or disorder Dust disease of the lung(s) Respiratory (toxic agents) Poisoning (chronic) Physical Agents (radiation, etc.) Repeated Trauma (noise, CTDs, etc.) Other Illness Not Applicable

  • Skin disease or disorder
  • Dust disease of the lung(s)
  • Respiratory (toxic agents)
  • Poisoning (chronic)
  • Physical Agents (radiation, etc.)
  • Repeated Trauma (noise, CTDs, etc.)
  • Other Illness
  • Not Applicable

• Reference: Complete List of all Causal Factors

  

• Causal Factor(s)

  Select Employee Supervision Equipment/Materials Other

  • Employee
  • Supervision
  • Equipment/Materials
  • Other

• Employee

  Select Physical Limitations Deficient in skill/ability Drugs/alcohol Lack of alertness Failure to follow written procedure Confined space entry LOTO Failure to follow oral instructions Failure to use PPE Operating without authority Taking an at risk position At risk speed (shortcut) Improper use of tool/equipment/material Use of incorrect tool/equipment/material Improper manual handling

  • Physical Limitations
  • Deficient in skill/ability
  • Drugs/alcohol
  • Lack of alertness
  • Failure to follow written procedure
  • Confined space entry
  • LOTO
  • Failure to follow oral instructions
  • Failure to use PPE
  • Operating without authority
  • Taking an at risk position
  • At risk speed (shortcut)
  • Improper use of tool/equipment/material
  • Use of incorrect tool/equipment/material
  • Improper manual handling

• Supervision

  Select Incorrect/incomplete procedures/instructions Rules/procedures not enforced Inadequate training of employee(s) Proper tools/equipment not provided Deficient storage/handling practices Inadequate housekeeping Rush by supervisor

  • Incorrect/incomplete procedures/instructions
  • Rules/procedures not enforced
  • Inadequate training of employee(s)
  • Proper tools/equipment not provided
  • Deficient storage/handling practices
  • Inadequate housekeeping
  • Rush by supervisor

• Equipment/Materials

  Select Defective equipment/tools/materials Inadequate or missing guards Inadequate or bypassed safety devices Inadequate maintenance/equipment/inspection Inadequate lighting Inadequate ventilation Inadequate design/layout (congestion) Inadequate fabrication/installation

  • Defective equipment/tools/materials
  • Inadequate or missing guards
  • Inadequate or bypassed safety devices
  • Inadequate maintenance/equipment/inspection
  • Inadequate lighting
  • Inadequate ventilation
  • Inadequate design/layout (congestion)
  • Inadequate fabrication/installation

• Other

  Select Horseplay/distraction by fellow employee Error by fellow employee Equipment/material/action of 3rd party Upset conditions Exposure to chemical/physical/biological agents Weather (rain/snow/ice/wind) Company sponsored activity Glass Other

  • Horseplay/distraction by fellow employee
  • Error by fellow employee
  • Equipment/material/action of 3rd party
  • Upset conditions
  • Exposure to chemical/physical/biological agents
  • Weather (rain/snow/ice/wind)
  • Company sponsored activity
  • Glass
  • Other

• Basic Cause(s)

  Select Lack of knowledge Not enforcing proper policies Engineering Inadequate PPE Purchasing inadequate/inferior equipment Lack of accountability Improper methods Inadequate inspection/maintenance

  • Lack of knowledge
  • Not enforcing proper policies
  • Engineering
  • Inadequate PPE
  • Purchasing inadequate/inferior equipment
  • Lack of accountability
  • Improper methods
  • Inadequate inspection/maintenance

• Immediate fix

5 Why (Root Cause)

• 1. Why did the incident happen?

• 2. Why did 1 happen?

• 3. Why did 2 happen

• 4. Why did 3 happen?

• 5. Why did 4 happen?

Corrective Actions

• Do the documented practices and assessments adequately cover the situation to prevent re-occurrence?

  Yes

  No

• If no, develop a corrective action

• Is the incident recordable and behavioral?

  Yes

  No

• If yes, develop a corrective action

• Is this incident a re-occurrence?

  Yes

  No

• If yes, develop a corrective action to address the re-occurrence and learn from what did not work last time

• Supervisor Corrective Action #1

• Responsible Person

• Target Date

  Date

• Supervisor Corrective Action #2

• Responsible Person

• Target Date

  Date

• Supervisor Corrective Action #3

• Responsible Person

• Target Date

  Date

• Employee Signature

  Sign

• Supervisor Signature

  Sign

• Department Manager

  Sign

• ORM Manager

  Sign

• Damage to company property will result in disciplinary action based on the following.

  

• Department

  Select Production Single Serve Maintenance Sanitation Warehouse Quality Other

  • Production
  • Single Serve
  • Maintenance
  • Sanitation
  • Warehouse
  • Quality
  • Other

• Process Area

  Bottling

  Bulk

  Main Kitchen

• Process Area

  DNS/SS Kitchen

  SSK/RS

• Describe Location

• Employee(s) Name

• Date and Time of Incident

  Date

• Date Reported

  Date

• Shift

  1st

  2nd

  3rd

• Time Employee(s) Began Work

  Date

• Employees usual job title

• Job at time of incident

• Length of time on the job before the incident had occurred

  In Training

  <1 Year

  >1 Year

• Describe in detail how the incident occured:

• Add pictures from incident here:

  Media

• Describe the work in progress (task) when the incident occurred

• Did anyone witness the incident?

  Yes

  No

• Who?

• Were statements recorded at the Nurse's station?

  Yes

  No

• Incident Type

  Select Caught in, under, between Contact by Contact with Fall from elevation Fall, same level Motor vehicle / PIT Struck against object Struck by object Other Slip Trip Overexertion / strain

  • Caught in, under, between
  • Contact by
  • Contact with
  • Fall from elevation
  • Fall, same level
  • Motor vehicle / PIT
  • Struck against object
  • Struck by object
  • Other
  • Slip
  • Trip
  • Overexertion / strain

• Contacted With/Contacted By

  Select Chemicals Electricity Temperature Extremes Equipment Noise Radiation Insect Bite Glass Other Not Applicable

  • Chemicals
  • Electricity
  • Temperature Extremes
  • Equipment
  • Noise
  • Radiation
  • Insect Bite
  • Glass
  • Other
  • Not Applicable

• Reference: Complete List of all Causal Factors

  

• Causal Factor(s)

  Select Employee Supervision Equipment/Materials Other

  • Employee
  • Supervision
  • Equipment/Materials
  • Other

• Employee

  Select Physical Limitations Deficient in skill/ability Drugs/alcohol Lack of alertness Failure to follow written procedure Confined space entry LOTO Failure to follow oral instructions Failure to use PPE Operating without authority Taking an at risk position At risk speed (shortcut) Improper use of tool/equipment/material Use of incorrect tool/equipment/material Improper manual handling

  • Physical Limitations
  • Deficient in skill/ability
  • Drugs/alcohol
  • Lack of alertness
  • Failure to follow written procedure
  • Confined space entry
  • LOTO
  • Failure to follow oral instructions
  • Failure to use PPE
  • Operating without authority
  • Taking an at risk position
  • At risk speed (shortcut)
  • Improper use of tool/equipment/material
  • Use of incorrect tool/equipment/material
  • Improper manual handling

• Supervision

  Select Incorrect/incomplete procedures/instructions Rules/procedures not enforced Inadequate training of employee(s) Proper tools/equipment not provided Deficient storage/handling practices Inadequate housekeeping Rush by supervisor

  • Incorrect/incomplete procedures/instructions
  • Rules/procedures not enforced
  • Inadequate training of employee(s)
  • Proper tools/equipment not provided
  • Deficient storage/handling practices
  • Inadequate housekeeping
  • Rush by supervisor

• Equipment/Materials

  Select Defective equipment/tools/materials Inadequate or missing guards Inadequate or bypassed safety devices Inadequate maintenance/equipment/inspection Inadequate lighting Inadequate ventilation Inadequate design/layout (congestion) Inadequate fabrication/installation

  • Defective equipment/tools/materials
  • Inadequate or missing guards
  • Inadequate or bypassed safety devices
  • Inadequate maintenance/equipment/inspection
  • Inadequate lighting
  • Inadequate ventilation
  • Inadequate design/layout (congestion)
  • Inadequate fabrication/installation

• Other

  Select Horseplay/distraction by fellow employee Error by fellow employee Equipment/material/action of 3rd party Upset conditions Exposure to chemical/physical/biological agents Weather (rain/snow/ice/wind) Company sponsored activity Glass Other

  • Horseplay/distraction by fellow employee
  • Error by fellow employee
  • Equipment/material/action of 3rd party
  • Upset conditions
  • Exposure to chemical/physical/biological agents
  • Weather (rain/snow/ice/wind)
  • Company sponsored activity
  • Glass
  • Other

• Basic Cause(s)

  Select Lack of knowledge Not enforcing proper policies Engineering Inadequate PPE Purchasing inadequate/inferior equipment Lack of accountability Improper methods Inadequate inspection/maintenance

  • Lack of knowledge
  • Not enforcing proper policies
  • Engineering
  • Inadequate PPE
  • Purchasing inadequate/inferior equipment
  • Lack of accountability
  • Improper methods
  • Inadequate inspection/maintenance

• EMPLOYEE PLACEMENT - Improper matching of the affected employee's skill set to what the job or specific task demands that led to an injury or incident.

• Immediate fix

5 Why (Root Cause)

• 1. Why did the incident happen?

• 2. Why did 1 happen?

• 3. Why did 2 happen

• 4. Why did 3 happen?

• 5. Why did 4 happen?

Corrective Actions

• Do the documented practices and assessments adequately cover the situation to prevent re-occurrence?

  Yes

  No

• If no, develop a corrective action

• Is the incident recordable and behavioral?

  Yes

  No

• If yes, develop a corrective action

• Is this incident a re-occurrence?

  Yes

  No

• If yes, develop a corrective action to address the re-occurrence and learn from what did not work last time

• Supervisor Corrective Action #1

• Responsible Person

• Target Date

  Date

• Supervisor Corrective Action #2

• Responsible Person

• Target Date

  Date

• Supervisor Corrective Action #3

• Responsible Person

• Target Date

  Date

• Employee Signature

  Sign

• Supervisor Signature

  Sign

• Department Manager

  Sign

• ORM Manager

  Sign

• Date and time of incident

  Date

• Describe the unsafe act

• Add pictures of the unsafe act here:

  Media

• Describe what was done to immediately improve, correct or respond to observation

• Did your actions correct the observation?

  Yes

  No

• If No, how should the observation be corrected?

• Date and time of incident

  Date

• Describe the unsafe condition

• Add pictures of the unsafe condition here:

  Media

• Describe what was done to immediately improve, correct or respond to observation

• Did your actions correct the observation?

  Yes

  No

• If No, how should the observation be corrected?

• Date and time of incident

  Date

• What was damaged (be specific)

• Party responsible for damage

• Name of individual(s) responsible

• Describe in detail how the incident occurred:

• Describe the work in progress (task) when the incident occurred

• Information obtained during or after the incident?

  Yes

  No

• Provide here:

• Was plant security or a member of management notified by the 3rd party of the damage

  Yes

  No

• File a report with local law enforcement if property was damaged and the responsible party left without notifying plant management/security. Local Police: 419-332-6464

• Pictures of damage

  Media

• Did anyone witness the incident?

  Yes

  No

• Who?

• Estimated cost of damage (needed for claim)

• CONSULT WITH OTHER CONTRACTOR THAT MAY BE ABLE TO ASSIST WITH DETERMING COST OF DAMAGES

5 Why (Root Cause)

• 1. Why did the incident happen?

• 2. Why did 1 happen?

• 3. Why did 2 happen

• 4. Why did 3 happen?

• 5. Why did 4 happen?

• Date and time of incident

  Date

• Describe the condition or act that could result in serious injury or harm

• Add pictures here:

  Media

• Describe what was done to immediately improve, correct or respond to observation

• Did your actions correct the observation?

  Yes

  No

• If No, how should the observation be corrected?