Incident Investigation Form

• Incident Investigation Title

• Location
  Address

• Personnel involved in the investigation

• Investigation Date

  Date

• Date and time of incident

  Date

Incident summary:

• Name of injured person or person reporting the incident

• What type of incident occurred

  Select Fatality Permanent disability Lost time accident Medical treatment Restricted work Serious near miss Near Miss Environmental incident Property Damage

  • Fatality
  • Permanent disability
  • Lost time accident
  • Medical treatment
  • Restricted work
  • Serious near miss
  • Near Miss
  • Environmental incident
  • Property Damage

• What was the injury type

  Select Strain Laceration Bruising Fracture Amputation Burn Crush Electric shock Other None

  • Strain
  • Laceration
  • Bruising
  • Fracture
  • Amputation
  • Burn
  • Crush
  • Electric shock
  • Other
  • None

• What was the injury category?

  Select Caught in pinch or nip Caught between or under Caught on Contact with electricity Contact with heat Contact with cold Contact with chemicals Contact with biological agents Contact with radiation Fall from height Fall on same level Struck by Struck against Electric shock Explosion Fire Ergonomics Noise Other Equipment failure No injury occurred

  • Caught in pinch or nip
  • Caught between or under
  • Caught on
  • Contact with electricity
  • Contact with heat
  • Contact with cold
  • Contact with chemicals
  • Contact with biological agents
  • Contact with radiation
  • Fall from height
  • Fall on same level
  • Struck by
  • Struck against
  • Electric shock
  • Explosion
  • Fire
  • Ergonomics
  • Noise
  • Other
  • Equipment failure
  • No injury occurred

• What body part was affected

  Select Fingers or hand Arm Leg Foot Torso Head Eye None

  • Fingers or hand
  • Arm
  • Leg
  • Foot
  • Torso
  • Head
  • Eye
  • None

• Provide a summary of the incident, giving as much detail as possible

• Add photographs where possible

  Media

Task being conducted:

• Enter details of task being conducted at time of incident

Other persons involved / witnesses

• Name

• Position

• Location at time of incident

Reference documentation:

• Procedure or training material used (if applicable)

Immediate Actions:

• List immediate actions taken as a result of the incident

Supplementary Actions:

• List actions taken to prevent reoccurrence

Timeline / Sequence of events:

• Describe the sequence of events from initial report and interviews

• Draw the timeline if possible

  Drawing

Contributing Factors: Task / Procedural

• Was a safe operating procedure available?

  Yes

  No

  N/A

• Was a safe work procedure used?

  Yes

  No

  N/A

• Was a risk assessment conducted prior to the incident?

  Yes

  No

  N/A

• Were controls in place as per the risk assessment?

  Yes

  No

  N/A

• Were appropriate tools and materials available?

  Yes

  No

  N/A

• Were they used?

  Yes

  No

  N/A

• Were personnel trained to conduct the work?

  Yes

  No

  N/A

Contributing Factors: Equipment / Substance

• Equipment was in good working order?

  Yes

  No

  N/A

• Was the equipment used as designed?

  Yes

  No

  N/A

• Equipment is regularly serviced?

  Yes

  No

  N/A

• Were pre-start checks conducted?

  Yes

  No

  N/A

• Were there any actions required from the pre-start checks?

  Yes

  No

  N/A

• Were the actions completed prior to operation?

  Yes

  No

  N/A

• Personnel were appropriately trained to operate equipment?

  Yes

  No

  N/A

• SDS (safety data sheet) are available?

  Yes

  No

  N/A

• All labels and signs in place and easy to read?

  Yes

  No

  N/A

• PPE required for the task?

  Yes

  No

  N/A

• Appropriate PPE is available?

  Yes

  No

  N/A

• PPE was worn correctly?

  Yes

  No

  N/A

Contributing Factors: Environment / Behaviour

• Was the weather conditions a factor of the incident?

  Yes

  No

  N/A

• Was the area clean and tidy?

  Yes

  No

  N/A

• Was it too hot or too cold?

  Yes

  No

  N/A

• Was it noisy?

  Yes

  No

  N/A

• Was lighting adequate?

  Yes

  No

  N/A

• Was fatigue evident?

  Yes

  No

  N/A

• Was alcohol or another impairment evident?

  Yes

  No

  N/A

• Was drug or alcohol testing completed immediately after the incident?

  Yes

  No

  N/A

• Was the task being rushed?

  Yes

  No

  N/A

• Were workers complacent?

  Yes

  No

  N/A

• Was poor vision a factor?

  Yes

  No

  N/A

• Were health issues a factor?

  Yes

  No

  N/A

• Workers were experienced and adequately supervised?

  Yes

  No

  N/A

Other Contributing factors:

• List any other contributing factors

• Add photos as required

  Media

Conclusions and Recommendations:

• What was the root cause?

  Task / Procedural

  Equipment / Substance

  Environment / Behaviour

  Other

Recommendations:

• Enter comments and recommendations

• Investigating officer name

• Signature of investigating officer

  Sign