Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
SECTION I
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Date and time of incident
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Date and time incident was reported.
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To whom was the incident reported? Eric Rovacsek
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Location of incident. (Specify site location)Pit 1
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Supervisor's Name Eric Rovacsek
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Supervisor's Phone Number0499 022 742
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Was there any witness(es)? If yes, provide name(s).No
Witness
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Name and Address
PERSON(S) INVOLOVED
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Person
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Name John Williams
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Phone: 0401 932 083
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Sex: Male
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Age; 30
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Job Title: Operator
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Time on job: (Yrs & Mos) 3 months
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Job Status: operator
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Classification:
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Medication prescribed? If yes list medications. No
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List Medications
NATURE OF INJURY
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Describe injury. N/A
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Detail any first-aid or medical treatment administered. (Provide names)
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Property Damage: yes
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Photo of damage.
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Property Damage:
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Photo of damage.
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Estimated cost of damage:$200
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Machinery /Vehicle Service Truck
Machinery /Vehicle
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Machinery/ Vehicle ID:JOH003
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Make/Model:Isuzu truck
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Age:3
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Detailed description of incident. (Include environmental conditions at time of incident) Manoeuvring u turn in pit in close quarters, reversed into windrow and bent rear bumper bar slightly.
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Environmental photo:
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Environmental photo:
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Immediate (Direct Causes): Positioned truck to close to windrow
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Direct cause photo:
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Direct cause photo:
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Contributing (underlying) Factors:
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Contributing factors photo:
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Corrective Action (Include detail description of action and person(s) responsible for actions) Use a spotter in future
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What was the potential for severity?<br>Low
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What could have potentially happened? Further damage to bumper
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What is the probability of reoccurrance?<br>Low
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Date 8/1/2015
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Signature Eric Rovacsek
