Incident/Acciedent/Near Miss Report - Full Investigation & Report

• Document No.

• Audit Title

• Client / Site / Project

• Investigation conducted on

  Date

• Prepared by

• Location
  Address

Incident/Accident/Near Miss Details (CIRCLE ONE)

• Date & Time of Incident/Accident/Near Miss

  Date
• Location of Incident/Accident/Near Miss
  Address

• Incident/Accident/Near Miss Severity?

  Urgent

  High

  Medium

  Low

  Trivial

• Vessel Name/Location

• Incident Type (select all that apply)

  Select Hazard Near-Miss Slip & Fall Accident Injury Theft Fire Property Damage Fatality Illness Reportable / Notifiable Loss Time Other

  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Reportable / Notifiable
  • Loss Time
  • Other

• Please describe type of incident

• Name of on-duty supervisor at time of incident?

• Was medical attention administered?

  Yes

  No

• What kind of medical attention was administered?

  Select First Aid Doctor Consulted Hospital Ambulance Medical Attention Declined

  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

• Please detail medical attention

Incident Summary

• Describe what happened. Please be detailed but state only facts.

• Do you wish to include a timeline of events for this incident?

  Yes

  No

Incident Timeline

• Build a timeline of key incident events below

Event

• Event Date / Time

  Date

• Event Description

• What were the weather / environmental conditions at the time of the incident?

  Select Clear Cloudy Rain Snow Windy Heatwave Haze Other

  • Clear
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Heatwave
  • Haze
  • Other

• Describe the weather / environmental conditions at the time of the incident

Evidence and Attachments

• Which of the following do you need to attach to this report to accuractly document this incident?

  Select Evidence Equipment Details Vehicle Details Damages Other Items

  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Evidence Log

• Please log all relevant evidence below

Evidence

• Evidence Description

• Evidence ID number (if applicable)

• Type of evidence

  Document

  Photos

  Other

• Photos of evidence (if applicable)

  Media

• Please detail any further information regarding this evidence (if applicable)

Damage Log

• Please log all relevant damage details below

Damage

• Damage description

• ID number (if applicable)

• Photos of damage (if applicable)

  Media

• Please detail any further information regarding this damage (if applicable)

Other Items Log

• Please log all relevant details of other items below

Item

• Item description

• ID number (if applicable)

• Photos of item (if applicable)

  Media

• Please detail any further information regarding this item (if applicable)

Equipment Log

• Please log all relevant equipment details below

Equipment

• Equipment Make

• Equipment Model

• Equipment ID number (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this equipment (if applicable)

People involved

• Please document all people involved in this incident

Person

Person

• Full Name

• ID number

• Contact phone number

• What is this person's relation to the incident? (select all that apply)

  Select Reporter of incident Injured person Witness Primary person involved Secondary Involvement On-duty supervisor Investigator Suspect Other

  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Suspect
  • Other

• Describe this person's relation to the incident

• Please describe this person's involvement with the incident, including all relevant information

• Attach any relevant photos regarding this person

  Media

• Do you want to log a statement for this person?

  Yes

  No

  N/A

Statement

• Statement regarding incident

• Person Signature

  Sign

• Date & Time of Statement

  Date

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Type of injury or illness? (select all that apply)

  Select Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & Spinal Cord Amputation Intracranial Other

  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & Spinal Cord
  • Amputation
  • Intracranial
  • Other

• Describe type of injury or illness

• Parts of body affected? (select all that apply)

  Select General Ailment Head Eye (Right) Eye (Left) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Right) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • General Ailment
  • Head
  • Eye (Right)
  • Eye (Left)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Right)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• Please describe injury location

• Describe this injury or illness

• What was the cause of this injury or illness?

Corrective Actions

• Are corrective/further actions required with regard to this incident?

  Yes

  No

• Please add any corrective actions to the appropriate questions above before completing this incident investigation

• Have all required corrective actions been added as Actions to this inspection?

  Yes

  No

  N/A

Root Cause Analysis / Contributing Factors

• What were the contributing factors to this incident occurring? (select all that apply)

  Select Equipment Defects Unauthorized Equipment Use Improper Equipment Use Lack of protective safety devices Employee operating at inappropriate speed Equipment used outside rated capacity Lack of PPE Inappropriate PPE Untidy Conditions (Poor Housekeeping) Safety procedures not followed Inadequate ventilation Drugs or Alcohol

  • Equipment Defects
  • Unauthorized Equipment Use
  • Improper Equipment Use
  • Lack of protective safety devices
  • Employee operating at inappropriate speed
  • Equipment used outside rated capacity
  • Lack of PPE
  • Inappropriate PPE
  • Untidy Conditions (Poor Housekeeping)
  • Safety procedures not followed
  • Inadequate ventilation
  • Drugs or Alcohol

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

• Has the root cause of this issue been able to be identified?

  Yes

  No

  N/A

• Why is the root cause for this issue unable to be identified at this time?

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

• What is the root cause of this incident? Please consider and include all contributing factors

• Has the root cause of this issue been rectified or eliminated?

  Yes

  No

• How was the root cause rectified or eliminated?

• Please attach any relevant photos or media

  Media

• Please provide any relevant further details

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name & Signature of Investigator

  Sign