Incident Investigation Report - AES

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Investigation Status

  Pending

  Completed

• Prepared by

• Business Unit

  Select MCBU GCBU ArkLaTex Other

  • MCBU
  • GCBU
  • ArkLaTex
  • Other

• Investigation Team

Incident Date/Time & Location

• Date And Time The Incident Occurred/Discovered:

  Date

• Date And Time The Incident Was Reported:

  Date

• Customer and Project:

• Incident Location:
  Address

Incident Classification

• Information Report / Non-Work Related

• Near Miss

• Property Damage

• Minor = Valued less than $5000.00 / Major = Valued more than $5000.00

  Estimate Pending

  Minor

  Major

• Injury

• Injury Classification:

  Minor First Aid

  First Aid

  Recordable

  Recordable - Restricted Duty

  Recordable - Lost Time

• Spill / Release

• Is the spill reportable? (More than 5bbl of liquid.)

  Non-Reportable

  Reportable

• Estimate Amount Spilled:

Employee Information

Employee

• Employee's Full Name:

• Employee ID Number:

• Employee Trade:

• Employee Gender:

  Male

  Female

• Employee's Date Of Birth:

  Date

• Short Service Employee?

  Yes

  No

• Employee's Phone Number:

• Injury / Illness

  Yes

  No

• Describe the location and nature of the injury:

• Was Injury Case Management Company/Person Contacted?

  Yes

  No

  N/A

• Describe Treatment:

• Was the Employee taken to a Medical Clinic or Hospital?

  Yes

  No

• Name, Location, and phone number of the Clinic.

• Name of the attending Physician.

• Was prescription medication administered or given?

  Yes

  No

  N/A

• Was the employee released to full duty? (If not, list restrictions)

  Yes

  No

  N/A

Property Damage

• Are there Property/Vehicle/Equipment/Utility Line Damages?

  Yes

  No

  N/A
Property Damage

• Describe Damage:

Vehicle Damage

• Vehicle Owner:

  Select Company Owned Employee Owned Customer or 3rd Party

  • Company Owned
  • Employee Owned
  • Customer or 3rd Party

• Unit Number:

• VIN (Vehicle Identification Number):

• License Plate:

• Describe Vehicle Damage:

• Unit Number:

• VIN (Vehicle Identification Number):

• License Plate:

• Describe Vehicle Damage:

• Vehicle Owner's Information:

• Vehicle Description (Y/M/M):

• Describe Vehicle Damage:

Equipment Damage

• Unit Number:

• Manufacturer (Make/Model):

• Equipment Type:

• Describe Damage:

Utility Damage

• Utility Damaged With:

  Select Auger Backhoe/Trackhoe Boring Grader/Scraper Hand Tools Trencher Unknown/Other

  • Auger
  • Backhoe/Trackhoe
  • Boring
  • Grader/Scraper
  • Hand Tools
  • Trencher
  • Unknown/Other

• Type of Utility:

  Select Electrical Line Telephone Line Television Cable Fiber Line Fiber Optic Line Pipeline (Gas/Oil) Water Line Sewer Line Other

  • Electrical Line
  • Telephone Line
  • Television Cable
  • Fiber Line
  • Fiber Optic Line
  • Pipeline (Gas/Oil)
  • Water Line
  • Sewer Line
  • Other

• Is the line regulated by the DOT?

  Yes

  No

  N/A

• Type of Pipeline Facility:

  Select Public - City Street Public - State Highway Public - County Road Public - Interstate Highway Public - Other Private - Business Private - Land Owner Private - Easement Pipeline Power/Transmission Line Dedicated Public Utility Easement Federal Railroad Data Not Collected Unknown/Other

  • Public - City Street
  • Public - State Highway
  • Public - County Road
  • Public - Interstate Highway
  • Public - Other
  • Private - Business
  • Private - Land Owner
  • Private - Easement
  • Pipeline
  • Power/Transmission Line
  • Dedicated Public Utility Easement
  • Federal
  • Railroad
  • Data Not Collected
  • Unknown/Other

• Depth of damaged utility line:

• Utility Owner:

• Cable / Line Size (inches):

• Type of underground pipeline facility affected:

  Distribution

  Gathering

  Service/Drop

  Transmission

  Unknown/Other

• Were Locates Requested?

  Yes

  No

  N/A

• Was the "One Call" Current?

  Yes

  No

  N/A

• One-Call Ticket Number:

• One Call Ticket Date:

• Check Damage Prevention Service:

  Texas811

  Lonestar811

  NM811

  Other

• One-Call Emergency Dig Up Ticket Number:

• Check Damage Prevention Service:

  Texas811

  Lonestar811

  NM811

  Other

• Emergency Dig Up Ticket Date:

• One-Call Emergency Dig Up Ticket Number:

• Check Damage Prevention Service:

  Texas811

  Lonestar811

  NM811

  Other

• Emergency Dig Up Ticket Date:

• Was The Utility Located?

  Yes

  No

  N/A

• Were The Locates Correct?

  Yes

  No

  N/A

• Was a "Blind Sweep" conducted?

  Yes

  No

  N/A

• We're all customer required permits completed?

  Yes

  No

  N/A

Description Of Events

• Brief Description Of Incident:

• Describe Treatment:

• Additional Investigation Information:

Root Cause Analysis

• Is a Root Cause Analysis applicable?

  Yes

  No

  N/A

• The 5 Why Process: This step involves asking the 5 Whys (why, why, why, why, why). Begin with the basic direct cause of the incident. Start by asking the first why to the direct cause. One why uncovers one reason and generates another why.
  
  Determine indirect cause (Hazardous Condition and Unsafe Behavior) from the sequence of events.

• Why (Question1):

• Why (Question2):

• Why (Question3):

• Why (Question4):

• Why (Question5):

• (Root Cause). This step should identify missing standards, controls that management did not design or failed to implement. Continue asking "why" in order to develop the information needed to establish root causes. Note: Root causes are program, management and/or system breakdowns or inadequacies. Determine system design and system implementation causes for each of the indirect causes.

• Corrective Action: List the Corrective Action to avoid future occurrences.

• Preventative Measures:

  Yes

  No

  N/A

• Preventative Measures:

• Attach Photos:

  Media

• Photo Notes:

• Diagrams:

  Drawing

Close Out

• All Information is correct and accurate.

  Yes

  No

  N/A
Auditor Name & Signature

• Auditor Name:

  Sign