Incident Investigation Report

• Conducted by

• Incident Number

• Date and Time the event occured

  Date

• Time shift started

  Date

• Length of shift

  10 hours

  12 hour

  Other (please comment)

• Shift

  Days

  Nights

• Department

  Select Ancillary Contractor Dewatering Maintenance Mill Mine Ore process Security Site admin Tech Services

  • Ancillary
  • Contractor
  • Dewatering
  • Maintenance
  • Mill
  • Mine
  • Ore process
  • Security
  • Site admin
  • Tech Services

• Which group

  Select General Store Golf Course Day Care Hadley Maintenance Warehouse/Purchasing Clinic

  • General Store
  • Golf Course
  • Day Care
  • Hadley Maintenance
  • Warehouse/Purchasing
  • Clinic

• Which contracting group

• Which maintenance group

  Fixed

  Electrical

  Mobile

• Which group

  Dispatch

  IT

  Operations

• Which group

  Met lab

  Pads

  Plants

  Refinery

• Which group

  Select Accounting CI Environmental HR Management Safety

  • Accounting
  • CI
  • Environmental
  • HR
  • Management
  • Safety

• Which group

  Select Assay lab Projects Survey Sampling Geotech Hydrology Geology

  • Assay lab
  • Projects
  • Survey
  • Sampling
  • Geotech
  • Hydrology
  • Geology

• Crew

  Select Crew 1 Crew 2 Crew 3 Crew 4 Straight days Crew A Crew B Other (please comment)

  • Crew 1
  • Crew 2
  • Crew 3
  • Crew 4
  • Straight days
  • Crew A
  • Crew B
  • Other (please comment)

• Is this a High potential incident or High potential near miss

  Yes

  No

• At this time does this appear to be a Critical Risk failure

  Yes

  No

• Will a MIIT team be used for this investigation

  Yes

  No

• Please select all team members

  Select Employee involved Employees peer Employees Supervisor Dpt. GF or Superintendent Employee trainer Safety Professional

  • Employee involved
  • Employees peer
  • Employees Supervisor
  • Dpt. GF or Superintendent
  • Employee trainer
  • Safety Professional

• Employees name

• Peers name

• Supervisors name

• GF or Superintendent name

• Trainers name

• Safety professional name

Notification Tree

• Basic notification tree

  

UA/BA determination

• Select for minimum requirement

  Select Near miss (low of moderate risk) Near miss (major or critical risk) Process loss Contact-No damage Property damage Injuries (FAST response) Injuries (Requiring medical attention)

  • Near miss (low of moderate risk)
  • Near miss (major or critical risk)
  • Process loss
  • Contact-No damage
  • Property damage
  • Injuries (FAST response)
  • Injuries (Requiring medical attention)

• 

• UA/BA conducted

  Yes

  No

Employee and witness section

• Are Employees involved

  Yes

  No

• Name of Person(s) involved

• Dept. experience in months

• RMGC experience in months

• Total experience with the task

• Job Title

• Rotation

  Select 7 and 7 4/5/5/4 4 tens 8 and 6 4/4/4/2 Other (comment required)

  • 7 and 7
  • 4/5/5/4
  • 4 tens
  • 8 and 6
  • 4/4/4/2
  • Other (comment required)

• Attach employee statment

  Media
Witness (add as many as required)

• Any witnesses?

  Yes

  No

• Provide name and job title

• Upload witness statement(s)

  Media

Type of investigation

• Please select type of investigation for this incident

  Select Full investigation (MIIT, High potential, CRM, injury) Short form (report only/spills)

  • Full investigation (MIIT, High potential, CRM, injury)
  • Short form (report only/spills)

Investigation Information and Immediate Causes

• Complete Description of the Incident: Describe where the event occurred, how the event occurred, including events leading up to and following the Incident

• Incident Type

  Select Near miss Injury Contact - No damage Property Damage Process Loss Environmental Impact Illness Fire Atmospheric release

  • Near miss
  • Injury
  • Contact - No damage
  • Property Damage
  • Process Loss
  • Environmental Impact
  • Illness
  • Fire
  • Atmospheric release

• Type of Injury

  Select Abrasion Amputation Burn Contusion Fracture Foreign Body Laceration Sprain Strain Exposure Other

  • Abrasion
  • Amputation
  • Burn
  • Contusion
  • Fracture
  • Foreign Body
  • Laceration
  • Sprain
  • Strain
  • Exposure
  • Other

• Affected Body Parts

  Select Abdomen Ankle Arm Back Chest Eye Finger Foot Hand Head Hip Knee Leg Neck Shoulder Toe Wrist Respiratory system Other (please comment)

  • Abdomen
  • Ankle
  • Arm
  • Back
  • Chest
  • Eye
  • Finger
  • Foot
  • Hand
  • Head
  • Hip
  • Knee
  • Leg
  • Neck
  • Shoulder
  • Toe
  • Wrist
  • Respiratory system
  • Other (please comment)

• Attach C-1 form

  Media

• Is the impact cyanide related?

  Yes

  No

• Was the reading 10ppm or higher?

  Yes

  No

• What was exact reading?

• Was area/plant evacuated?

  Yes

  No

• Was Safety on Call contacted?

  Yes

  No

• Please select environmental impact type

  Spill

  Wildlife mortality

• Attach spill report

  Media

• Attach mortality report

  Media

• Which chemical?

  Select HCN - Cyanide H2S - Hydrogen Sulfide Hg - Mercury NO2 - Nitrogen Dioxide NH3 - Ammonia SO2 - Sulfur Dioxide Other

  • HCN - Cyanide
  • H2S - Hydrogen Sulfide
  • Hg - Mercury
  • NO2 - Nitrogen Dioxide
  • NH3 - Ammonia
  • SO2 - Sulfur Dioxide
  • Other

• Was the reading 10ppm or higher?

  Yes

  No

• What was exact reading?

• Was area/plant evacuated?

  Yes

  No

• Was Safety on Call contacted?

  Yes

  No

• Please select environmental impact type

  Spill

  Wildlife mortality

• Attach spill report

  Media

• Attach mortality report

  Media

• Physical Activity

  Select Climbing Driving Kneeling Lifting Reaching Sitting Standing Twisting Walking Other

  • Climbing
  • Driving
  • Kneeling
  • Lifting
  • Reaching
  • Sitting
  • Standing
  • Twisting
  • Walking
  • Other

• Please describe

• Work Activity at Time of Incident

  Select Operating mobile equipment Mobile equipment repairs Plant operation Operating small vehicle Passenger Facility repairs Material handling Office Task Other (Please comment)

  • Operating mobile equipment
  • Mobile equipment repairs
  • Plant operation
  • Operating small vehicle
  • Passenger
  • Facility repairs
  • Material handling
  • Office Task
  • Other (Please comment)

• Contact or Exposure Type

  Select Abnormal Operation Caught Between/Under Caught In Caught On Environmental Release Equipment Failure Ergonomic Fall - Lower Level/Fall to same level Overexertion Overpressure Overstress Struck Against Struck By No contact near miss

  • Abnormal Operation
  • Caught Between/Under
  • Caught In
  • Caught On
  • Environmental Release
  • Equipment Failure
  • Ergonomic
  • Fall - Lower Level/Fall to same level
  • Overexertion
  • Overpressure
  • Overstress
  • Struck Against
  • Struck By
  • No contact near miss

• Contact Source

  Select Chemical Dust Electricity Falling Object Flying Object Heat/Cold Loss of Control Machinery Noise Other (please comment) Near miss no source

  • Chemical
  • Dust
  • Electricity
  • Falling Object
  • Flying Object
  • Heat/Cold
  • Loss of Control
  • Machinery
  • Noise
  • Other (please comment)
  • Near miss no source

• Which Chemical?

• Immediate Causes (normally present at the scene)

  Select Substandard Acts Substandard Conditions

  • Substandard Acts
  • Substandard Conditions

• Please Select substandard actions

  Select Failure to Communicate/Coordinate Failure to follow SOP Failure to Identify Hazard and/or Risk Failure to Secure Failure to Warn Horseplay Improper Lifting Improper Loading Improper Loading Improper Placement Improper Position for Task Improper Use of PPE Improper Use of Equipment Making Safety Devices Inoperative Servicing Equipment in Operation Use of Defective Equipment Other (please comment)

  • Failure to Communicate/Coordinate
  • Failure to follow SOP
  • Failure to Identify Hazard and/or Risk
  • Failure to Secure
  • Failure to Warn
  • Horseplay
  • Improper Lifting
  • Improper Loading
  • Improper Loading
  • Improper Placement
  • Improper Position for Task
  • Improper Use of PPE
  • Improper Use of Equipment
  • Making Safety Devices Inoperative
  • Servicing Equipment in Operation
  • Use of Defective Equipment
  • Other (please comment)

• Please select substandard conditions

  Select Congested/Restricted Area Defective Tools/Equipment/Materials Fire/Explosive Hazard Inadequate Guards/Barriers Inadequate Instruction/Procedure Inadequate Preparation/Planning Inadequate Protective Equipment Inadequate Warning System Poor Housekeeping/Disorder Road Condition Weather Condition Other (please Comment)

  • Congested/Restricted Area
  • Defective Tools/Equipment/Materials
  • Fire/Explosive Hazard
  • Inadequate Guards/Barriers
  • Inadequate Instruction/Procedure
  • Inadequate Preparation/Planning
  • Inadequate Protective Equipment
  • Inadequate Warning System
  • Poor Housekeeping/Disorder
  • Road Condition
  • Weather Condition
  • Other (please Comment)

Fatigue Related Incidents

• What is potentially fatigue related

  Yes

  No

• Does the employee believe this event could be due to a medical condition? If so, please stop the assessment and contact the on call HR person

  Yes

  No

Fatigue Cause

• To the best of their ability can the employee explain why they are fatigued

  Select Stress Lack of sleep Use of medicine Grief/Sadness Sedentary job/task Other (please comment)

  • Stress
  • Lack of sleep
  • Use of medicine
  • Grief/Sadness
  • Sedentary job/task
  • Other (please comment)

Work Schedule

• Work Schedule

  Scheduled Shift

  Call Out/Overtime

  Extended Shift

• How many hours have been worked

  Select 0-2 3-4 5-6 7-8 9-10 11-12 Greater than 12 hours

  • 0-2
  • 3-4
  • 5-6
  • 7-8
  • 9-10
  • 11-12
  • Greater than 12 hours

• Has the employee taken a break during shift

  Yes

  No

• Has the employee taken a break during shift

  Yes

  No

• Has the employee taken a break during shift

  Yes

  No

• Has the employee taken a break during shift

  Yes

  No

• Has the employee taken a break during shift

  Yes

  No

Signs and Symptoms

• Physical

  Select Yawning Heavy eyelids Rubbing eyes head drooping None observed Other

  • Yawning
  • Heavy eyelids
  • Rubbing eyes
  • head drooping
  • None observed
  • Other

• Emotional

  Select More quiet than usual Mood changes, low tolerance or irritability Lack of energy Emotional outburst, aggression, rage None observed Other

  • More quiet than usual
  • Mood changes, low tolerance or irritability
  • Lack of energy
  • Emotional outburst, aggression, rage
  • None observed
  • Other

• Mental

  Select Difficulty concentrating on the task Difficulty remembering what you are doing Failure to communicate important information Accidentally doing the wrong thing Lapses in attention Failure to anticipate events/actions None observed Other

  • Difficulty concentrating on the task
  • Difficulty remembering what you are doing
  • Failure to communicate important information
  • Accidentally doing the wrong thing
  • Lapses in attention
  • Failure to anticipate events/actions
  • None observed
  • Other

Sleep Wake History

• How much sleep have you had in the past 24 hours

  Select 2 3 4 5 6 7 8

  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8

• How much sleep have you had in the past 48 hours

  12-16

  7-11

  2-6

Scene

• Photos of scene/damage/area

  Media

• What were the general conditions at the work area

  Select Congested area Slick conditions Cluttered (housekeeping) Cold/Hot Wind Clean, orderly, good conditions Other (Comments required)

  • Congested area
  • Slick conditions
  • Cluttered (housekeeping)
  • Cold/Hot
  • Wind
  • Clean, orderly, good conditions
  • Other (Comments required)

• Add comments

• Did the conditions contribute to the incident

  Yes

  No

• Please explain

• Was the incident scene altered prior to investigation (equipment moved etc.)

  Yes

  No

• Please describe

• Was any equipment involved?

  Yes

  No

• Equipment Type

• Manufacturer

• Model Number

• RMGC Equipment Number

• Damage Type

  Select Mobile Equipment Structural Machinery Small Vehicle Utility Other None

  • Mobile Equipment
  • Structural
  • Machinery
  • Small Vehicle
  • Utility
  • Other
  • None

• Work Order #

• Estimated Cost of Property Damage and/or Process Loss

• Work Order #

• Estimated Cost of Property Damage and/or Process Loss

• Work Order #

• Estimated Cost of Property Damage and/or Process Loss

• Work Order #

• Estimated Cost of Property Damage and/or Process Loss

• Work Order #

• Estimated Cost of Property Damage and/or Process Loss

• Please specify

• Work Order #

• Estimated Cost of Property Damage and/or Process Loss

Corrective Actions and Notifications

• Description of the Immediate Corrective Actions - Briefly describe what Actions were taken to correct/mitigate the consequences of the event.

• Complete your portion of the investigation by clicking your department for notification

  Select Ancillary Contractor Dewatering Environmental Maintenance Mine Mill/OP Projects Security Tech Services Administration

  • Ancillary
  • Contractor
  • Dewatering
  • Environmental
  • Maintenance
  • Mine
  • Mill/OP
  • Projects
  • Security
  • Tech Services
  • Administration

Managements investigation Section (HOD)

• Did an injury or illness occur?

  Yes

  No

• Please select the effect of injury/illness

  Select First Aid Medical Treatment Restricted Work Lost Time Fatal

  • First Aid
  • Medical Treatment
  • Restricted Work
  • Lost Time
  • Fatal

• What type of care was given?

  FAST

  EMT

  Clinic

  Transport

• Incident Loss

  Select Equipment Repair/Replace Property Damage Production/Process Loss Injury/Illness Treatment Other (please comment)

  • Equipment Repair/Replace
  • Property Damage
  • Production/Process Loss
  • Injury/Illness Treatment
  • Other (please comment)

• Estimated Cost

• Actual Cost

• Was a work order issued?

  Yes

  No

• Work Order#

• Please describe

• Estimated Cost

• Actual Cost

• Was a work order issued?

  Yes

  No

• Work Order#

• Estimated Cost

• Actual Cost

• Was a work order issued?

  Yes

  No

• Work Order#

• Estimated Cost

• Actual Cost

• Was a work order issued?

  Yes

  No

• Work order#

• Estimated Cost

• Actual Cost

• Use the matrix to rank the risk potential

  

• Rank the potential risk

  Critical

  Major

  Moderate

  Low

• Basic Cause(s) of Incident (Use appendix C to complete)

  Select Improper motivation Inadequate work standards Inadequate leadership and or supervision Inadequate communications Physical or physiological stress Inadequate purchasing Inadequate physical/physiological capability Mental or psychological stress Inadequate engineering Inadequate tools and equipment Inadequate maintenance Lack of skill Abuse or Misuse Lack of knowledge Excessive wear and tear

  • Improper motivation
  • Inadequate work standards
  • Inadequate leadership and or supervision
  • Inadequate communications
  • Physical or physiological stress
  • Inadequate purchasing
  • Inadequate physical/physiological capability
  • Mental or psychological stress
  • Inadequate engineering
  • Inadequate tools and equipment
  • Inadequate maintenance
  • Lack of skill
  • Abuse or Misuse
  • Lack of knowledge
  • Excessive wear and tear

• Areas requiring Correction (Use appendix D to complete)

  Select Leadership and administration Emergency Preparedness Planned Inspection and Maintenance Critical task analysis and procedures Incident investigation Task Observation Standards/Work permits Incident analysis Knowledge/Skill training Personal protective equipment health and hygiene control System evaluation Engineering/change management Personal communications Group communications General promotion Hiring and placement Materials and service management Off the job safety Environmental management Quality management

  • Leadership and administration
  • Emergency Preparedness
  • Planned Inspection and Maintenance
  • Critical task analysis and procedures
  • Incident investigation
  • Task Observation
  • Standards/Work permits
  • Incident analysis
  • Knowledge/Skill training
  • Personal protective equipment
  • health and hygiene control
  • System evaluation
  • Engineering/change management
  • Personal communications
  • Group communications
  • General promotion
  • Hiring and placement
  • Materials and service management
  • Off the job safety
  • Environmental management
  • Quality management

• Was the incident a result of

  Select Lack of standards Inadequate standards Non-compliance with standards

  • Lack of standards
  • Inadequate standards
  • Non-compliance with standards
Corrective Actions

• Individual(s) will be assigned to review, revise, develop, manage, coordinate or assume responsibility for the following corrective actions

• Action Item

• Assigned to

• Target Date

  Date

• Completion Date

  Date

• Completion verified by

Final Risk Assessment

• Will this be classified as a Critical risk failure

  Yes

  No

• The Final Risk Assessment is

  Critical

  Major

  Moderate

  Low

• The Risk is

  Acceptable

  Unacceptable

• Please comment and continue analysis and correction process until final risk is acceptable or practice is abandoned

• Photos of corrections if possible

  Media

Signatures and Approvals

• Head of Department Signature

  Sign

• Head of Health and Safety Department Signature

  Sign

• Operations Manager Signature

  Sign

• General Manager Signature

  Sign

• Complete Description of the Incident: Describe where the event occurred, how the event occurred, including events leading up to and following the Incident

• Incident Type

  Select Near miss Injury Contact - No damage Property Damage Process Loss Environmental Impact Illness Fire Atmospheric release

  • Near miss
  • Injury
  • Contact - No damage
  • Property Damage
  • Process Loss
  • Environmental Impact
  • Illness
  • Fire
  • Atmospheric release

• Type of Injury

  Select Abrasion Amputation Burn Contusion Fracture Foreign Body Laceration Sprain Strain Exposure Other

  • Abrasion
  • Amputation
  • Burn
  • Contusion
  • Fracture
  • Foreign Body
  • Laceration
  • Sprain
  • Strain
  • Exposure
  • Other

• Affected Body Parts

  Select Abdomen Ankle Arm Back Chest Eye Finger Foot Hand Head Hip Knee Leg Neck Shoulder Toe Wrist Respiratory system Other (please comment)

  • Abdomen
  • Ankle
  • Arm
  • Back
  • Chest
  • Eye
  • Finger
  • Foot
  • Hand
  • Head
  • Hip
  • Knee
  • Leg
  • Neck
  • Shoulder
  • Toe
  • Wrist
  • Respiratory system
  • Other (please comment)

• Attach C-1 form

  Media

• Description of the Immediate Corrective Actions - Briefly describe what Actions were taken to correct/mitigate the consequences of the event.

• Send to Incident investigation review team for approval

• Is the impact cyanide related

  Yes

  No

• Please select environmental impact type

  Spill

  Wildlife mortality

COMPLETE SPILL REPORT

• Date and Time spill occurred

  Date

• Type of material spilled

QUANTITY & CONCENTRATION

• Is quantity known

  Yes

  No

• State quantity

• Please choose quantity calculation

  Select Volume of soil/material contaminated equals (ft3) Total quantity in Gallons Percent of spilled material in soil or percent soil moisture Weight of spilled material in the soil in pounds If applicable, pounds of cyanide in spilled solution

  • Volume of soil/material contaminated equals (ft3)
  • Total quantity in Gallons
  • Percent of spilled material in soil or percent soil moisture
  • Weight of spilled material in the soil in pounds
  • If applicable, pounds of cyanide in spilled solution

• Amount Volume of soil/material

• Amount in gal

• Percent of spilled material

• Weight of spilled material

• Pounds of cyanide

• Duration of spill (i.e., 1 minute, 4 hours, two days)

• Was the material puddled/ponded

  Yes

  No

• Exact location on mine site where the spill occurred

• Do you know the cause of the spill?

  Yes

  No

• Please describe and include equipment ID# if applicable.

• How did you find the spill? Please include equipment ID# if applicable.

• What type of material was contaminated?

  Packed Haul Road

  Native Soil

  Waste Rock

  Other

• Please be specific

• How was the spill contained?

• How was it cleaned up?

• How much contaminated material was removed? (cubic feet or cubic yards)

• Where was the contaminated material taken?

• Action taken to prevent re-occurance

FINALIZING SPILL REPORT

• Date and Time spill clean up was completed

  Date

• Person responsible for spill report

  Sign

• Position of person responsible for spill report

• Supervisor/Manager

  Sign

• Attach mortality report

  Media

• Attach C-1

  Media

• Description of the Immediate Corrective Actions - Briefly describe what Actions were taken to correct/mitigate the consequences of the event.

• Send to Incident investigation review team for approval

• Which chemical?

  Select HCN - Cyanide H2S - Hydrogen Sulfide Hg - Mercury NO2 - Nitrogen Dioxide NH3 - Ammonia SO2 - Sulfur Dioxide Other

  • HCN - Cyanide
  • H2S - Hydrogen Sulfide
  • Hg - Mercury
  • NO2 - Nitrogen Dioxide
  • NH3 - Ammonia
  • SO2 - Sulfur Dioxide
  • Other

• Was the reading 10ppm or higher?

  Yes

  No

• What was exact reading?

• Was area/plant evacuated?

  Yes

  No

• Was Safety on Call contacted?

  Yes

  No

Corrective Actions and Notifications

• Description of the Immediate Corrective Actions - Briefly describe what Actions were taken to correct/mitigate the consequences of the event.

• Complete your portion of the investigation by clicking your department for notification

  Select Ancillary Contractor Dewatering Environmental Maintenance Mine Mill/OP Projects Security Tech Services Administration

  • Ancillary
  • Contractor
  • Dewatering
  • Environmental
  • Maintenance
  • Mine
  • Mill/OP
  • Projects
  • Security
  • Tech Services
  • Administration