Title Page
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Date & Time
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Department
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Incident Report
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Department:
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Date of incident:
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Time of incident:
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Ref. No
2. Investigation Team - Name Surname and Designation
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Chairman: Name and Surname
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Investigator: Name and Surname
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H & S Rep: Name and Surname
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Supervisor: Name and Surname
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Injured Person: Name and Surname
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Date of investigation
3. Type of Incident
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Injury on Duty
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Environmental Spill
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Fire on Site
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Equipment Damage
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Occupational Disease
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Near Miss
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)
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Description of Incident
5. Direct result/ consequences of incident on:
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Production Hours
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Production tons/ units
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Man hours
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Cost
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Quality
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Safety
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Equipment
6. Root Cause Analysis Worksheet
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Define the problem:
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Why is it happening?
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Why is that?
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Why is that?
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Why is that?
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Why is that?
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Unsafe condition
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Unsafe act
7. Secondary Contributing Factors
Factors
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Inadequate communication
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Inadequate design of plant or equipment
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Poor housekeeping and waste management
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Lack/ inadequate procedure or standard
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Unauthorised modifications/ changes
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Lack/ inadequate warning system
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Lack of exposure
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Operating equipment without permission
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Lack of supervision
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Using equipment improperly
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Time at work or on the job
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Inadequate PPE
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Length of service in section
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Failing to follow procedure
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Lack of focus
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Incorrect tools used
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Lack of skill
8. RISK RATING
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SEVERITY/ CONSEQUENCE CRITERIA
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LIKELIHOOD/ FREQUENCY CRITERIA:
9. Corrective/ Preventative Action
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1.
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By Whom
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Target Date:
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2.
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By Whom
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Target Date
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3.
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By Whom
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Target Date:
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4.
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By Whom:
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Target Date
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5.
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By Whom
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Target Date
10. Reportable to
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11. Was the incident reported to Department of Labour?
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12. Was the incident/ reported to Compensation Commissioner?
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13. Was accident/ incident reported to the Police?
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14. Police Station:
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15. Police Case number:
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Signature of Chairman of investigation
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Signature of Supervisor
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Signature Chairman of H&S Committee
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Signature of SHE Rep
