Incident Investigation Report Form

• Nature Of Incident:

• Conducted on:

  Date

• Prepared by:

• Location of Incident:

Injured Employee Data

• Employee Name

• Working Title

• Personnel Telephone Number

• Date & Time of Incident

  Date

• What date did the IE come on duty?

  Date

• How long into their current shift did the incident occur?

• Work or Client Location Name

• Was the IE a Short Service Employee?

  Yes

  No

  N/A

• Who was their mentor and were they with them at the time of the incident?

  Yes

  No

  N/A

• Supervisor

• Supervisor Telephone Number

• Supervisor Email

• Workers Comp Claim Number (if known)

Incident Description:

• 1. Where did the incident happen and who was involved? Provide a full description of the surroundings of the location and the individuals involved.

• 2. What was happening at the time of the incident and why was it taking place?

• 3. What events lead up to the incident? Describe the sequence in order and when they took place.

• 4. What exactly caused the injury and how did it happen? What mechanics, equipment or tools were involved?

• 5. Describe the injury. Include the affected body part(s) and injury type or indicate no injury occurred.

• 6. If a physical injury was avoided, describe what happened that could have potentially resulted in injury?

Additional Information

• Provide any additional information important to the investigation (pictures taken, evidence collected).

  Media

Significant Injury or Fatality (SIF)

• Did this incident have a potential to be a Significant Injury or Fatality (SIF) ?

  Yes

  No

  N/A

• What was the task being completed?

• What controls were in place?

• Were any controls missing?

• What were the amplifiers?

Initial Investigator:

• Incident Investigator Name

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CHECK ALL DIRECT CAUSES THAT APPLY

• What CONDITION of tools, equipment, or work area contributed to incident?

  Select Close Clearance/Congestion Hazardous Placement Inadequate Warning System Improper Material Storage Inadequate/Improper PPE Floors/Work Surfaces Inadequate Ventilation Inadequate Illumination Inadequate Guards/Barrier Equipment/Workstation Design Poor Housekeeping Equipment Failure Hazardous Materials Defective Tools/Equipment/Vehicle Other Not Applicable

  • Close Clearance/Congestion
  • Hazardous Placement
  • Inadequate Warning System
  • Improper Material Storage
  • Inadequate/Improper PPE
  • Floors/Work Surfaces
  • Inadequate Ventilation
  • Inadequate Illumination
  • Inadequate Guards/Barrier
  • Equipment/Workstation Design
  • Poor Housekeeping
  • Equipment Failure
  • Hazardous Materials
  • Defective Tools/Equipment/Vehicle
  • Other
  • Not Applicable

• Other

• What ACTION or INACTION contributed to the incident?

  Select Failure to Make Secure Improper Lifting Used Equipment Improperly Operating Procedure Deviation Horseplay/Distractive Active Nullified Safety/Control Devices Servicing Equipment In Motion Used Defective Equipment Improper Technique Unauthorized Actions Improper Position Unsafe Act of Another Staff Running/Rushing/Acting In Haste Failure to Use PPE Improper Loading Operating At Improper Speed Used Wrong Tool/Equipment Under Influence Drugs/Alcohol Failure to Warn/Signal Other Not Applicable

  • Failure to Make Secure
  • Improper Lifting
  • Used Equipment Improperly
  • Operating Procedure Deviation
  • Horseplay/Distractive Active
  • Nullified Safety/Control Devices
  • Servicing Equipment In Motion
  • Used Defective Equipment
  • Improper Technique
  • Unauthorized Actions
  • Improper Position
  • Unsafe Act of Another Staff
  • Running/Rushing/Acting In Haste
  • Failure to Use PPE
  • Improper Loading
  • Operating At Improper Speed
  • Used Wrong Tool/Equipment
  • Under Influence Drugs/Alcohol
  • Failure to Warn/Signal
  • Other
  • Not Applicable

• Other

CHECK ALL UNDERLYING OR ROOT CAUSES THAT APPLY

• What caused or influenced the substandard conditions or behaviors?

  Select Lack of Proper Procedures Inadequate Job Training Methods Inadequate Maintenance Standards Poor Work Design Lack of Communication Between Staff Inadequate Cleaning Inadequate Preventive Maintenance Inadequate Job Instructions Inadequate Supervision Unsafe Design or Construction Inadequate Purchasing Standards Improper Extension of Service Life Inadequate Environmental Controls Inadequate Enforcement or Work Standards Inadequate Tools Improper Layout or Design Poor Work Practice Lack of Skill Improper Planning Inadequate Capacity Other

  • Lack of Proper Procedures
  • Inadequate Job Training Methods
  • Inadequate Maintenance Standards
  • Poor Work Design
  • Lack of Communication Between Staff
  • Inadequate Cleaning
  • Inadequate Preventive Maintenance
  • Inadequate Job Instructions
  • Inadequate Supervision
  • Unsafe Design or Construction
  • Inadequate Purchasing Standards
  • Improper Extension of Service Life
  • Inadequate Environmental Controls
  • Inadequate Enforcement or Work Standards
  • Inadequate Tools
  • Improper Layout or Design
  • Poor Work Practice
  • Lack of Skill
  • Improper Planning
  • Inadequate Capacity
  • Other

• Other

CHECK ALL ACTIONS NECESSARY TO CORRECT THE DIRECT AND ROOT CAUSES

• What corrective actions have been taken or are needed to prevent a recurrence?

  Select Task Analysis/Procedure Revision Reinstruction of Employees Eliminate Congestion Task Analysis to Be Completed Improve Design/Construction Improve Illumination Improve Clean-Up Procedures Improve Storage/Arrangement Improve/Change Work Method Install/Revise Guards/Devices Job Reassignment of Employees Mandatory Pre-Job Instructions Repair/Replace Equipment Rotation of Employee Identify/Improve PPE Improve Enforcement Use Other Materials/Supplies Improve Ventilation Other

  • Task Analysis/Procedure Revision
  • Reinstruction of Employees
  • Eliminate Congestion
  • Task Analysis to Be Completed
  • Improve Design/Construction
  • Improve Illumination
  • Improve Clean-Up Procedures
  • Improve Storage/Arrangement
  • Improve/Change Work Method
  • Install/Revise Guards/Devices
  • Job Reassignment of Employees
  • Mandatory Pre-Job Instructions
  • Repair/Replace Equipment
  • Rotation of Employee
  • Identify/Improve PPE
  • Improve Enforcement
  • Use Other Materials/Supplies
  • Improve Ventilation
  • Other

• Other

5 Why Root Cause Analysis

• Loss

• Why?

• Why?

• Why?

• Why?

• Why?

• Sub Root: Failure Classification

• Root Cause: Failure Classification

• Supervisor

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• QHSE Manager

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• District Manager

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• Safety Representative

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