Incident Investigation

• Site conducted

  Select

• Name of Employee:

• Designation of Employee:

  Select General Worker Chainsaw Operator Artisan Driver Supervisor Management

  • General Worker
  • Chainsaw Operator
  • Artisan
  • Driver
  • Supervisor
  • Management

• Clock Number:

• Area of Department/Team:

  Select Kubusi Fort Cunynghame Isedenge Hogsback Maintenance Workshop Roads Security

  • Kubusi
  • Fort Cunynghame
  • Isedenge
  • Hogsback
  • Maintenance
  • Workshop
  • Roads
  • Security

• Department/Team

  Select Ketile Tete Ntonga Petche Nkohlo Nathu Axola Mpongo Ricardo Workshop Gadlela Lose Unathi Roads Rangers Kwedinana Mlandu Patrick Nkewana Salaried Staff

  • Ketile
  • Tete
  • Ntonga
  • Petche
  • Nkohlo
  • Nathu
  • Axola
  • Mpongo
  • Ricardo
  • Workshop
  • Gadlela
  • Lose
  • Unathi
  • Roads
  • Rangers
  • Kwedinana
  • Mlandu
  • Patrick
  • Nkewana
  • Salaried Staff

• Location of Incident

• Date and Time of Incident:

  Date

• Date and Time Incident Reported:

  Date

• Conducted on:

  Date

• Prepared by:

  Select Abongile Pama Lukhanyo Mabongo Siya Toni Ian Welsh Tristan De Wit Andre Van Deventer Chris Everton Reece Daniel Jonathan Norman Ian Taylor Travis Howes Nolitha Mabutya Gideon van Lill Anele Bakajana

  • Abongile Pama
  • Lukhanyo Mabongo
  • Siya Toni
  • Ian Welsh
  • Tristan De Wit
  • Andre Van Deventer
  • Chris Everton
  • Reece Daniel
  • Jonathan Norman
  • Ian Taylor
  • Travis Howes
  • Nolitha Mabutya
  • Gideon van Lill
  • Anele Bakajana

• Supervisor:

• Safety Rep:

Loss

• What type of incident was this?

  Select Fatality LTI/Disabling Incident Medical Treatment Case First Aid Case Near Miss Vehicle Accident Property Damage (Excluding Vehicles)

  • Fatality
  • LTI/Disabling Incident
  • Medical Treatment Case
  • First Aid Case
  • Near Miss
  • Vehicle Accident
  • Property Damage (Excluding Vehicles)

• Case Number:

• Driver Name:

• Vehicle Registration:

• Is there a 3rd party involved

  Yes

  No

• Has Group Services been notified?

  Yes

  No

• Claim Number:

• If accident has taken place on a public road, has SAPS been notified?

  Yes

  No

• AR Number:

• Is there damage to the vehicle?

  Yes

  No

• Description of Damage:

• Cost of Damage: R

• Asset Number:

• Description of Damage:

• Cost of Damage: R

• Is this an insurance claim?

  Yes

  No

  NA

• Has Group Services been notified?

  Yes

  No

  NA

• Type of work being performed?

  Select Slashing Spraying Burning Pitting Planting Blanking Fertilizing Pruning Marking for Thinning Enumeration Other:

  • Slashing
  • Spraying
  • Burning
  • Pitting
  • Planting
  • Blanking
  • Fertilizing
  • Pruning
  • Marking for Thinning
  • Enumeration
  • Other:

• Specify:

• Short Description Of Incident (What happened and How?)

• Has the Manager investigated and found negligence on the part of any employee involved?

  Yes

  No

• Reason:

• Is the employee liable for the repair cost?

  Yes

  No

Injury Details

• Is this a work related incident?

  Yes

  No

  NA

• Expected Period of Disablement:

  Select 0 Days 1 - 13 Days 2 - 4 Weeks 4 - 16 Weeks 16 - 52 Weeks 52 Weeks + or Permanent Disablement Fatality NA

  • 0 Days
  • 1 - 13 Days
  • 2 - 4 Weeks
  • 4 - 16 Weeks
  • 16 - 52 Weeks
  • 52 Weeks + or Permanent Disablement
  • Fatality
  • NA

• Nature of Injury:

  Select Sprains Strains Contusion Laceration Wounds Fractures Unconscious Burns Amputation Bites/Stings Swallowed Other NA

  • Sprains
  • Strains
  • Contusion
  • Laceration
  • Wounds
  • Fractures
  • Unconscious
  • Burns
  • Amputation
  • Bites/Stings
  • Swallowed
  • Other
  • NA

• Specify:

• Accident Type:

  Select Struck By Stepped Into Walked Into Fall Same Level Fall Diff. Level Inhalation/Absorbtion Ionising Radiation Caught In Caught Between Foreign Body Other NA

  • Struck By
  • Stepped Into
  • Walked Into
  • Fall Same Level
  • Fall Diff. Level
  • Inhalation/Absorbtion
  • Ionising Radiation
  • Caught In
  • Caught Between
  • Foreign Body
  • Other
  • NA

• Specify:

• Part of Body:

  Select Head Eye Neck Trunk Arm Hand Finger Back Leg Knee Foot Internal Other: NA

  • Head
  • Eye
  • Neck
  • Trunk
  • Arm
  • Hand
  • Finger
  • Back
  • Leg
  • Knee
  • Foot
  • Internal
  • Other:
  • NA

• Specify:

Root Cause Analysis (5 why's)

• Why: ... (specify your question)

• Answer:

Recommended steps to prevent reoccurance:

• undefined

Action taken by employer to prevent the recurrence of a similar incident:

• undefined

undefined

• Employee Signature:

  Sign

• Safety Rep Signature:

  Sign

• Supervisor Signature:

  Sign

• Investigator Signature:

  Sign

• Group OHS Officer Signature:

  Sign

• Safety Committee Chairman:

  Sign