Incident with or without Injury

Incident Reference Number. Use the following format to create your unique reference number. Example: Department Number followed by date of incident: 02-051125 (Dyehouse-date)

• Incident Reference # (Format: Department Number followed by date: 12-051125):

• Did this incident result in damage to any property or company assets (machinery, grounds, facility, etc)? If so, describe.

• Did this incident result in any product loss (damaged goods) or production loss (production halted for any amount of time). If so, describe (what, how much, length of time etc).

• Did this incident result in any injury?

  Yes

  No

  N/A

• Short Incident Description

• Department and Supervisor

• Investigation conducted on:

  Date

• Prepared by

• Location
  Address

• Investigation Team

Incident Categorization

• Choose Hazard Category:

  Select Chemical Physical/Environmental Electrical Machinery/Equipment Bodily Injury-Accident Psychosocial Biological Ergonomic

  • Chemical
  • Physical/Environmental
  • Electrical
  • Machinery/Equipment
  • Bodily Injury-Accident
  • Psychosocial
  • Biological
  • Ergonomic

• Choose Incident Type:

  Select Near Miss Equipment/property Slips, trips, falls Faulty/misfunctioning/dangerous machinery Working at heights Confined Spaces Electrical Noise Vibration Temperature extremes Exposure to Toxic Chemicals: Dust/fumes/chemicals/solvents/paint/adhesives Inhalation/Respiratory Eyes/Vision Skin-Burns, irritation,reaction Heavy lifting/pushing/pulling Static tasks (long periods of standing/sitting) Repetitive tasks Violence/harassment/discrimination Stress Inadequate lighting Walking/working surfaces

  • Near Miss
  • Equipment/property
  • Slips, trips, falls
  • Faulty/misfunctioning/dangerous machinery
  • Working at heights
  • Confined Spaces
  • Electrical
  • Noise
  • Vibration
  • Temperature extremes
  • Exposure to Toxic Chemicals: Dust/fumes/chemicals/solvents/paint/adhesives
  • Inhalation/Respiratory
  • Eyes/Vision
  • Skin-Burns, irritation,reaction
  • Heavy lifting/pushing/pulling
  • Static tasks (long periods of standing/sitting)
  • Repetitive tasks
  • Violence/harassment/discrimination
  • Stress
  • Inadequate lighting
  • Walking/working surfaces

• 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?

• If there was an injury: Choose all injury types that are applicable (what injury did occur or could have occured if a near miss)

  Select Soft tissue: lacerations/puncture/abrasions etc Traumatic Brain Injury: concussions/skull fracture etc. Eye/Vision Injury Hearing loss Respiratory-Inhalents (dust, chemical, toxin etc) Repetitive tasks Static tasks: prolonged sitting/standing Prolonged movement: walking/climbing stairs/lifting Exposure to harmful substances Crushing/pinching/pulling Amputation Spinal Cord Injury Psychological: Trama, stress, anxiety Injury due to acts of violance Musculoskeletal Injuries: Sprains, strains, fractures, dislocations, back injuries, knee injuries, and shoulder injuries

  • Soft tissue: lacerations/puncture/abrasions etc
  • Traumatic Brain Injury: concussions/skull fracture etc.
  • Eye/Vision Injury
  • Hearing loss
  • Respiratory-Inhalents (dust, chemical, toxin etc)
  • Repetitive tasks
  • Static tasks: prolonged sitting/standing
  • Prolonged movement: walking/climbing stairs/lifting
  • Exposure to harmful substances
  • Crushing/pinching/pulling
  • Amputation
  • Spinal Cord Injury
  • Psychological: Trama, stress, anxiety
  • Injury due to acts of violance
  • Musculoskeletal Injuries: Sprains, strains, fractures, dislocations, back injuries, knee injuries, and shoulder injuries

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

• Take as many photos of the scene as possible and attach.

  Media

• Were safeguards or PPE used?

  Yes

  No

  N/A

• Were safeguards or safety equipment provided?

  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

Incident Analysis

• Here you will identify what the problem is, the cause, and the corrective actions to correct it. An answer example of an incident investigation using this process will be given in each section.

• Choose problem category:

  Select Exposed Electrical wiring Walking surface poorly maintained: holes, cracks, uneven surface etc. Missing/inadequate machine guards No PPE available or required Poor housekeeping: spills, clutter, obsticals Inadequate lighting Uncovered cords/cables Other Electrical Lacking Preventive Maintenace Behavioral: Unsafe practices, carelessness, improper technique etc. Lack of training Poor process/procedure Faulty machine or tools Weather conditions Working surfaces poorly maintained Lack of signage: Caution/danger/risk signage calling attention to hazard. Lack of fall protection

  • Exposed Electrical wiring
  • Walking surface poorly maintained: holes, cracks, uneven surface etc.
  • Missing/inadequate machine guards
  • No PPE available or required
  • Poor housekeeping: spills, clutter, obsticals
  • Inadequate lighting
  • Uncovered cords/cables
  • Other Electrical
  • Lacking Preventive Maintenace
  • Behavioral: Unsafe practices, carelessness, improper technique etc.
  • Lack of training
  • Poor process/procedure
  • Faulty machine or tools
  • Weather conditions
  • Working surfaces poorly maintained
  • Lack of signage: Caution/danger/risk signage calling attention to hazard.
  • Lack of fall protection

Problem Statement

• The problem statement refers to the safety event or failure that happened AND the result of that event.
  Example Problem: Ex: Employee slipped and broke his arm.

• State the problem:

RCA (Root Cause Analysis): 5 Whys

• The purpose of an RCA is to address the actual problem, instead of just the symptoms of the problem. To accomplish this, you will answer WHY this problem or failure (stated above) occurred. Then you will follow that by answering WHY to each subsequent answer.
  Example Process:
  Ex: Q: Why did the employee fall? A: There was hydraulic fluid on the floor.
  Q: Why was there hydraulic fluid on the floor? A: The forklift used was leaking, and the employee did not know it.
  Q: Why did the employee not know? A: The Employee did not check for oil leaks before operating the forklift.
  Q: Why didn't he check for leaks? A: Because checking for oil leaks is not on the pre-operational inspection checklist that the operator completes each shift.
  You will often identify more than one cause of a failure. Please identify ALL causes using this method, followed by corrective actions in the next section.
  

Why

• Question

• Answer

• Question

• Answer

• Question

• Answer

• Question

• Answer

• Question

• Answer

Root Cause Identification: List all root causes identified.

• RC1: What is the root cause of this incident?

• RC2: What is the root cause of this incident?

• RC3: What is the root cause of this incident?

• RC4: What is the root cause of this incident?

• RC5: What is the root cause of this incident?

Corrective Action(s):

• List any corrective actions that have been or will be taken.
  Example Problem:
  Ex: 1. Add "check for leaks" to pre-operations checklist and retrain. 2. Improve the process for identifying and cleaning spills, including supplying each department with caution floor signs until cleaned and dried. 4. Increase the preventive maintenance schedule to ensure proper equipment functioning.

• Did this problem require an immidiate corrective action to prevent further injury/damage etc? If so, what action was taken? (Ex: Forklift was put out of operation and oil cleaned from the floor)

• Enter suggested corrective action plans to address the root cause identified above. List in number order to reference Root Cause identified above: Each "Why" in the previous section may result in a corresponding corrective action. (Use section for "additional information" if needed).

• Please add any other pertinent information here:

Supporting Evidence

• Add any sources you used to investigate the incident. (Training records, maintenance records, operations manual, other documentation, photos, sketches etc.)

  Drawing

Finalization

• Involved Employee Signature and Date

  Sign

• Preparers Signature and Date:

  Sign

• Department Supervisor Signature and Date:

  Sign

Additional Information:

• Date and time of approval

  Date

• Approver's signature

  Sign