Incident Investigation

• Document No.

• Short Incident Description

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Investigation Team

Incident Investigation

• Take as many photos of the scene as possible.

  Media

• Describe, in detail, what occurred. Include the exact task being done and any relevant events leading up to the incident.

• What type of incident occurred?

  Spill

  Near Miss

  Equipment Damage

  Injury

  Other

• Date and time of incident

  Date

• Date and time employee began work

  Date

• Name of Injured Employee

• Department and Shift of Injured Employee

• Employment Status of Injured Person

  Permanent

  Temporary

  Contractor

  Visitor

• Describe injury and parts of body affected

• What object/substance directly injured the employee

• Injured Employee: State in your own words description of pain/discomfort and location of injury.

• Pain from scale 1-10

• Was on-site first aid treatment given?

  Yes

  No

• Who administered first aid?

• What first aid was performed? (ice, bandage, anti-bacterial cream, etc.)

• Is the employee requesting/in need of medical attention? Tap HERE to enter details.

  Yes

  No

• Contact the Safety Manager immediately!

• Was the employee transported to a local medical establishment?

  Yes

  No

• Where was the employee taken for treatment?

• Investigator: Give accurate description of nature and extent of injury and state your objective findings

• Investigator: Describe the nature of the damaged equipment. What was damaged? To what extent? Is the equipment operable? Does it pose additional risk to operators in it's current state?

• What material spilled?

• Approximately how much material spilled?

  <5 gal

  5-25 gal

  25-100 gal

  100+ gal

• Did the spill enter a local waterway?

  Yes

  No

• Report this incident immediately to the Safety Manager!

• Were safeguards or safety equipment provided?

  Yes

  No

  N/A

• Were safeguards or safety equipment used?

  Yes

  No

  N/A

Witness Statement

• Witness name

• Occupation

• Telephone number

• Date and Time of injury

  Date

• Location where injury occurred.

• Describe what you saw.

• Who or what caused the accident/injury?

• In your opinion what body parts were injured?

• Was there anything that could have been done to prevent injury?

  Yes

  No

• What could have been done?

• Did anything appear suspicious about the incident?

  Yes

  No

• What was suspicious?

• Witness signature

  Sign

Root Cause Analysis (5 Why's)

• Why?

Why

• Question

• Answer

• What is the root cause of this incident?

Immediate Corrective Action

• Enter corrective actions taken to prevent immediate reoccurrence. Enter suggestions for future corrective actions. Each "Why" in the previous section may result in a corresponding corrective action.

Finalization

• Employee signature

  Sign

• Preparers signature

  Sign