Incident Investigation

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Select date

  Date

Reporting

• What type of incident are you reporting

  AAW

  NM

  RTC

• Have you reported this Incident on the SOLARS system?

  Yes

  No

  N/A

• Is this incident likely to lead to an over 7 day absence?

  Yes

  No

  N/A

• If the answer to the last question is yes, have you informed your Health and Safety Advisor?

  Yes

  No

  N/A

Gathering Information

• Who was involved

• What happened

• We're there any witnesses?

  Yes

  No

  N/A

• Please enter any witness details and contact information here

• What equipment was being used at the time of the incident?

• We're all of the correct procedures being followed at the time of the incident?

  Yes

  No

  N/A

• If no, please describe why

• What was the immediate cause of the incident

  Select Manual handling Slip trip fall same level animal or insect fall from height use of hand tools use of power tools contact with electricity struck by object step on strike against struck by moving vehicle

  • Manual handling
  • Slip trip fall same level
  • animal or insect
  • fall from height
  • use of hand tools
  • use of power tools
  • contact with electricity
  • struck by object
  • step on strike against
  • struck by moving vehicle

• If an injury has occurred, what was the IP actually doing at the time the incident took place and immediately prior to the incident?

• We're any first aid measures required

  Yes

  No

  N/A

• Please enter who applied any first aid and the location

• What PPE was being used at the time of the incident?

• What were the sequence of events that led to this incident taking place?

• Please enter any sketches and measurements here

  Drawing

• Take photograph

  Media

Analysing the Information

• What was the root cause of this incident taking place

• What was the Root Cause of this incident taking place

  Select communication failure to secure failure to use equipment horseplay housekeeping improper lifting pressure to complete procedures tools&equipment under the influence drink/drugs

  • communication
  • failure to secure
  • failure to use equipment
  • horseplay
  • housekeeping
  • improper lifting
  • pressure to complete
  • procedures
  • tools&equipment
  • under the influence drink/drugs

Corrective/preventative actions

• What corrective/preventative actions are required to prevent same or similar types of incidents happening in the future

• Who is responsible for implementing these actions

• What time scale has been set to implement these actions

• Are extra resources required to assist the implementation of these actions

  Yes

  No

  N/A

• If the answer to the last question is yes, what are they and who have you contacted to arrange them

Action plan and implementation

• Have you fully implemented your action plan

  Yes

  No

  N/A