Investigation

INTRODUCTION

  • Summary of Incident

  • Immediate Actions

INVESTIGATION TEAM

  • Team Leader

  • Team Names

INDICATION OF INJURIES

  • Where there any injuries?

  • Details of person(s) involved in incident

  • Employment Status

  • Details of Injury

  • Photographs

  • Select area of injury?

INDICATION OF DAMAGE TO PROPERTY/ KEY PLANT INVOLVED

  • Was there any Property Damage?

  • Photographs of damage

  • Key Plant and Equipment involved in Incident

  • Equipment Name, Serial number, Manufacturer, managed by?

  • Photographs

WITNESSES

  • Where there any witnesses?

  • Record Details Of Witnesses

INVESTIGATION DETAIL

  • Sketch / diagram if required

  • Pre -incident Events (list activities occurring prior to the incident)

  • Sequence Of Events (list the event in chronological order)

  • Post Incident Events (list the activities undertaken after the event)

OBSERVATIONS (include any contributing factors)

  • Oservations

  • Other Provide Details?

CONCLUSIONS (immediate cause and contributing factors)

  • CONCLUSIONS?

  • Individual and Team Actions
  • Task and Environmental Conditions - Workplace
  • Task and Environmental Conditions - Human Factors
  • Organisational Factors
  • Absent or failed defences

RECOMMENDATIONS (include any corrective, preventive actions)

  • Recommendations? (Action, responsible, completion date)

FURTHER ACTIONS

  • Further Actions

PHOTOGRAPHS

  • Photographs

REPORT COMPLETED BY

  • INVESTIGATION COMPLETED BY:

  • DATE

  • Report Distribution

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