Incident Investigation Report

• Date & Time

  Date

• Department

  Select

• undefined

• Department:

• Date of incident:

  Date

• Time of incident:

  Date

• Ref. No

2. Investigation Team - Name Surname and Designation

• Chairman: Name and Surname

• Investigator: Name and Surname

• H & S Rep: Name and Surname

• Supervisor: Name and Surname

• Injured Person: Name and Surname

• Date of investigation

  Date

3. Type of Incident

• Injury on Duty

  Yes

  No

  N/A

• Environmental Spill

  Yes

  No

  N/A

• Fire on Site

  Yes

  No

  N/A

• Equipment Damage

  Yes

  No

  N/A

• Occupational Disease

  Yes

  No

  N/A

• Near Miss

  Yes

  No

  N/A

4. Detail description of incident (Name of affected person, part of body affected, effect on person, expected period of disablement, machine/ process involved, type of work performed if injury on duty and description of incident)

• Description of Incident

5. Direct result/ consequences of incident on:

• Production Hours

  Text answer

  N/ A

• Production tons/ units

  Text answer

  N/ A

• Man hours

  Text answer

  N/ A

• Cost

  Text answer

  N/ A

• Quality

  Text answer

  N/ A

• Safety

  Text answer

  N/ A

• Equipment

6. Root Cause Analysis Worksheet

• Define the problem:

• Why is it happening?

• Why is that?

• Why is that?

• Why is that?

• Why is that?

• Unsafe condition

  Yes

  No

  N/A

• Unsafe act

  Yes

  No

  N/A

7. Secondary Contributing Factors

Factors

• Inadequate communication

  Yes

  No

  N/A

• Inadequate design of plant or equipment

  Yes

  No

  N/A

• Poor housekeeping and waste management

  Yes

  No

  N/A

• Lack/ inadequate procedure or standard

  Yes

  No

  N/A

• Unauthorised modifications/ changes

  Yes

  No

  N/A

• Lack/ inadequate warning system

  Yes

  No

  N/A

• Lack of exposure

  Yes

  No

  N/A

• Operating equipment without permission

  Yes

  No

  N/A

• Lack of supervision

  Yes

  No

  N/A

• Using equipment improperly

  Yes

  No

  N/A

• Time at work or on the job

  Yes

  No

  N/A

• Inadequate PPE

  Yes

  No

  N/A

• Length of service in section

  Yes

  No

  N/A

• Failing to follow procedure

  Yes

  No

  N/A

• Lack of focus

  Yes

  No

  N/A

• Incorrect tools used

  Yes

  No

  N/A

• Lack of skill

  Yes

  No

  N/A

8. RISK RATING

• SEVERITY/ CONSEQUENCE CRITERIA

  Drawing

• LIKELIHOOD/ FREQUENCY CRITERIA:

  Drawing

9. Corrective/ Preventative Action

• 1.

• 2.

• 3.

• 4.

• 5.

10. Reportable to

• 11. Was the incident reported to Department of Labour?

  Text answer

  N/ A

• 12. Was the incident/ reported to Compensation Commissioner?

  Text answer

  N/ A

• 13. Was accident/ incident reported to the Police?

  Text answer

  N/ A

• 14. Police Station:

  Text answer

  N/ A

• 15. Police Case number:

  Text answer

  N/ A

• Signature of Chairman of investigation

  Sign

• Signature of Supervisor

  Sign

• Signature Chairman of H&S Committee

  Sign

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• Signature of SHE Rep

  Sign