Quality Investigation (5 whys)

• NCR / CAR Number#

Event Notification and Investigation Record

• It is a requirement of this site that all incidents and accidents no matter how minor are reported to the ########### or delegate immediately upon the incident occurring. This is to ensure that the area can be made secure if an investigation into the incident is required. Under no circumstances is a worker to enter or continue work in an area where an incident has occurred.

• It is the responsibility of the ########### or delegate to determine if the site requires to be secured for the purposes of investigation.

• Below is a flow diagram of the reporting and investigation process:

Location of Incident

• Location

  a

Event Title

• Enter Event Title:

Report Entered by:

• Name:

PART 1 – Notification - Event details, must be completed for ALL event reports) Refer to the attached incident notification flow chart.

• Event Date & Time:

  Date

• Event Reported Date & Time:

  Date

• Event Reported to:

• Witness Name/s:

• Event Description:

• Event Diagram:

  Media

• Exact Event Location:

• Was there a delay in reporting to either internal or external personnel

  Yes

  No

  N/A

• Provide details:

• Was a supplier or contractor involved in the incident?

  Yes

  No

  N/A

• Provide details:

Event Type: Quality

• Was the event a Quality incident?

  Yes

  No

  N/A

• Select the applicable event category:

  Select QTY - Customer Concern / Complaint QTY - Incorrect product / specification QTY - Property / Product damage QTY - Audit QTY -Internal System Breakdown QTY - Request for Information QTY - Internal Quality Incident QTY - Subcontractor / Supplier Issue QTY - Other

  • QTY - Customer Concern / Complaint
  • QTY - Incorrect product / specification
  • QTY - Property / Product damage
  • QTY - Audit
  • QTY -Internal System Breakdown
  • QTY - Request for Information
  • QTY - Internal Quality Incident
  • QTY - Subcontractor / Supplier Issue
  • QTY - Other

• Customer:

• Customer reference:

• Procedure / Process:

• Product Involved:

• Other information:

PART 2 - Cost

• Are there any costs associated with this incident?

  Yes

  No

  N/A

• If yes, please complete the below:

Involved Equipment

• Equipment Name / Type:

• Estimated Cost:

Involved Business Process

• Process Name / Type:

• Description:

• Estimated Cost:

Total Cost ( Equipment + Business Process)

• Estimated Total Cost:

PART 3 – Consequence Risk Ranking - includes immediate corrective actions & initial sign off

• Refer to table for Consequence Risk Ranking:

• Actual Event Level

  Level 1

  Level 2

  Level 3

  Level 4

  Level 5

• Potential Event Level

  Level 1

  Level 2

  Level 3

  Level 4

  Level 5

Contributing Factors (Basic investigation only - 5 WHYS)

• Were there any Behavioural Causes? If yes, select all that apply below:

  Yes

  No

  N/A

• Fatigued?

• Procedure / Specification not appropriate?

• Procedure / Specification not completed?

• Procedure / Specification not followed?

• Risk assessment / JSEA / SLAM not appropriate?

• Risk assessment / JSEA / SLAM not completed?

• Stresses?

• Supervision not adequate?

• Task design not appropriate?

• Time pressure?

• Training insufficient?

• Unauthorised behaviour?

• Unprofessional behaviour?

• Working after hours?

• Working alone?

• Equipment not used correctly?

• Other, describe?

• Add additional information for each checked box?

• Physical Causes. If yes, select all that apply below:

  Yes

  No

  N/A

• Equipment malfuctioning?

• Equipment not appropriate?

• Flooring?

• Safety equipment malfunctioning?

• Safety equipment not appropriate?

• Safety equipment not used?

• Weather?

• Workplace design not appropriate?

• Workplace poorly maintained?

• Uncategorised cause?

• Other, describe?

• Add additional information for each checked box:

Immediate Corrective Actions

• Action 1:

• Action 2:

• Action 3:

• Action 4:

• Provide further actions if required:

Person Completing Event Report:

• Name

• Date & Time

  Date

• Signature

  Sign

PART 4 - ICAM Process

• For all Actual Level 1 & 2 events, Parts 1, 2, 3, & 5 are to be completed.

• For all Actual Level 3 events and greater, Parts 1, 2, 3, 4 & 5 MUST be completed.

• Refer to the ICAM - Incident Investigation Reference Guide for assistance (located on SharePoint)

• Is a full ICAM required for this incident

  Yes

  No

  N/A

• Please complete investigation in the Quality Incident (ICAM) form.

PART 5 - Sign-off

Initial Sign-off

Supervisor Acceptance and Comments

• Name:

• Signature:

  Sign

• Date & Time:

  Date

• Comments:

Involved Person Acceptance and Comments

• Name:

• Signature:

  Sign

• Date & Time:

  Date

• Comments:

########### Acceptance and Comments

• Name:

• Signature:

  Sign

• Date:(dd/mm/yy)

  Date

• Comments:

########### Acceptance and Comments

• Name:

• Signature:

  Sign

• Date:(dd/mm/yy)

  Date

• Statutory Reporting Requirements:

  Yes

  No

  N/A

• Completed:

  Yes

  No

  N/A

• Corrective Actions Required:

  Yes

  No

  N/A

• Completed:

  Yes

  No

  N/A

• Communication to personnel (specify medium and date (i.e. safety meeting, TBT, audit, KPI's, other))

• Review Date:

  Yes

  No

  N/A

• Comments:

  Yes

  No

  N/A

Final Sign Off (actions have been completed and verified by #########)

• Name:

• Signature:

  Sign

• Date & Time:

  Date

• Comments: