Title Page

  • NCR / CAR Report 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

Event Title

  • Enter Event Title:

Report Entered by:

  • Name:

Incident / Event Notification

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

  • Event Date & Time:

  • Event Reported Date & Time:

  • Event Reported to:

  • Witness Name/s:

  • Event Description:

  • Event Diagram:

  • Exact Event Location:

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

  • Provide details:

  • Was a supplier or contractor involved in the incident?

  • Provide details:

Event Type: Quality

  • Was the event a Quality incident?

  • Select the applicable event category:

  • Customer:

  • Customer reference:

  • Procedure / Process:

  • Product Involved:

  • Other information:

PART 2 - Cost

  • Are there any costs associated with this incident?

  • 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

  • Potential Event Level

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

  • Complete the below sections

Analysis of Contributory Factors

Absent & Failed Defences

  • Are there any Absent or Failed Defences that contributed to the event? If yes, complete the below section.

  • Defences are those measures designed to prevent the consequences of a human act or component failure producing an incident. Defences are equipment or procedures for detection, warning, recovery, containment, escape and evacuation, as well as individual awareness and protective equipment. These contributing factors results from inadequate or absent defences that failed to detect and protect the system against technical and human failures. These are the control measures which did not prevent the incident or limit its consequences.

  • NOTE: Absent / Failed Defences are inanimate and may fail or be absent due to an Individual / Team Action, Task / Environmental Condition or an Organisational Factor. There does not have to be a direct link to an action.

  • Check question: Does this contributing factor describe the equipment, work process, control measure, detection system, procedure or attribute which normally prevents this incident or limits the consequences?

  • AFD = Absent Failed Defences

  • AFD1: Detection systems / procedures?

  • AFD2: Protection systems / procedures?

  • AFD3: Warning systems / procedures?

  • AFD4: Guards or barriers?

  • AFD5: Recovery systems / procedures?

  • AFD6: Escape systems / procedures?

  • AFD7: Rescue systems / procedures?

  • AFD8: PPE?

  • AFD9: Hazard identification?

  • AFD10: Risk Management?

  • AFD11: Safe work procedure?

  • AFD12: Supervision?

  • AFD13: Other? (specify)

Individual / Team Actions

  • Are there any Individual / Team actions that contributed to the event? If yes, complete the below section.

  • These are the errors or violations that led directly to the incident. They are typically associated with personnel having direct contact with the equipment, such as operators or maintenance personnel. They are always committed 'actively' (someone did or didn't do something) and have a direct relation with the incident. For most of the time however, the defences built into our operations prevent these 'human errors' from causing harm. Once again, keep asking "WHY?" someone acted (or was allowed to act) or didn't act in the way they might have leading up to the incident.

  • NOTE: These are active failures so they will have a verb attached. Fatigue, stress or drug / alcohol are behavioural influences that led to the error or violation.

  • Check question: Does this contributing factor tell you about an error or violation of a standard or procedure made in the presence of a hazard?

  • IT = Individual Team

  • IT1: Supervision?

  • IT2: Authority?

  • IT3: Operating speed?

  • IT4: Equipment use?

  • IT5: PPE?

  • IT6: Work procedure followed?

  • IT7: Equipment / material handling

  • IT8: Safety compliance?

  • IT9: Instructions given?

  • IT10: Training for task?

  • IT11: Experience for task?

  • IT12: Misconduct?

  • IT13: Other? (specifiy)

Task / Environmental Conditions

  • Are there any Task / Environmental conditions that contributed to the event? If yes, complete the below sections for Workplace & Human Factors.

  • These are the conditions in existence immediately prior or at the time of the incident that directly influence human and equipment performance in the workplace. These are the circumstances under which the errors and violations took place and can be embedded in task demands, the work environment, individual capabilities and human factors. Deficiencies in these conditions can promote the occurrence of errors and violations. They may also stem from an Organisational Factor Type such as Risk Management, Training, Incompatible Goals, or Organisation, when the system tolerates their long term existence.

  • The Task / Environmental Conditions are categorised into two groups: Workplace Factors and Human Factors. Within the two groups we can categories factors which encourage the commission of errors or violations and common factors which may promote errors and/or violations.

  • Check question: Does this contributing factor describe something about the task demands, work environment, individual capabilities or human factors that promoted errors / violations or undermined the effectiveness of the system's defences?

  • Workplace Factors Impact (WF)

  • WF1: Lighting

  • WF2: Weather

  • WF3: Dust / Contaminants / Noise

  • WF4: Working environment / culture

  • WF5: Wildlife

  • WF6: Surface gradient / conditions

  • WF7: Workplace access / restrictions

  • WF8: Housekeeping

  • WF9: Tools / equipment condition / availability

  • WF10: Task planning / operation

  • WF11: Routine / non-routine task

  • WF12: Abnormal operational situation / condition

  • WF13: Risk perception / management

  • WF14: Inadequate training / supervision

  • WF15: Other (specify)

  • Human Factors Impact (HF)

  • HF1: Complacency / motivation

  • HF2: Drugs / Alcohol

  • HF3: Familiarity with task

  • HF4: Fatigue

  • HF5: Time pressure

  • HF6: Peer pressure

  • HF7: Physical capabilities

  • HF8: Mental capabilities

  • HF9: Physical Stress

  • HF10: Mental Stress

  • HF11: Confidence level

  • HF12: Secondary goals / external factors

  • HF13: Personality

  • HF14: Other (specify)

Organisational Factors

  • Were there any Organisation Factors that contributed to the event? If yes, complete the below section.

  • The next step of the analysis is to identify which of the Organisational Factor Types (OFTs) are primarily implicated in producing the identified Task / Environmental Conditions, allowed them to go unaddressed or undermined the system's defences. These are the underlying organisational factors that produce the conditions that affect performance in the workplace. They may lie dormant or undetected for a long time within an organisation and only become apparent when they combine with other contributing factors that led to the incident. These may include management decisions, processes and practices.

  • Check question: Does this contributing factor identify a standard Organisational Factor present before the incident and which: produced adverse task / environmental conditions, or allowed them to unaddressed; promoted or passively tolerated errors or violations and / or undermined or removed the system defences?

  • HW: Hardware

  • TR: Training

  • OR: Organisation

  • CO: Communication

  • IG: Incompatible Goals

  • PR: Procedures

  • MM: Maintenance Management

  • DE: Design

  • RM: Risk Management

  • MC: Management of Change

  • CM: Contractor Management

  • OC: Organisation Culture

  • RI: Regulatory Influence

  • OL: Organisational Learning

  • VM: Vehicle Maintenance

  • MS: Management System

Immediate, Correct or Preventative Actions

  • Guidelines for Raising Corrective Actions

  • The investigation should identify recommendations for corrective actions to prevent recurrence, reduce risk and advance safety. This can best be achieved by addressing all absent or failed defences and organisational factors identified by the ICAM analysis. Not all contributing factors can be completely eliminated, and some may be eliminated only at a prohibitive cost. The investigation team should work with line management in the development of corrective actions.

    Recommendations must have a direct link back to the incident and must target: Prevention of recurrence and Reduction of risk. Recommendation must address each Absent or failed defences and Organisational Factor.

    The corrective actions recommended by the investigation team should be SMARTER (Specific, Measurable, Accountable, Reasonable, Timely, Effective, Reviewed).

  • Each recommendation is a written statement of the action management should take to correct a contributing factor. The team reviews each contributing factor and:

    • Formulates recommendations which, if implemented, will reduce the likelihood of that factor contributing to future incidents;
    • Recommends improvement to the system defences to limit the consequences of the contributing factor, so that residual risk is recognised by management as acceptable;
    • Makes interim recommendations for immediate corrective actions after an incident or near-miss as a short-term measure to mitigate current risks prior to the establishment of long-term
    corrective actions.

    It is essential any corrective action be fully evaluated by Management to ensure change/s do not weaken other defences or expose other risks. A recommendation must address an organisational or systemic deficiency; it should not be a one-time or band-aid fix.

    Recommendations should be based upon the Hierarchy of Control (refer to the Risk Management Procedure for further information).

    Each recommendation is numbered individually to ensure and simplify action assignment and completion control. The investigation should cross reference their recommendations to the identified absent / failed defences and organisational factors to ensure they have all been addressed.

Immediate, Corrective or Preventative Actions

  • Include person responsible and due date:

  • Action 1:

  • Action 2:

  • Action 3:

  • Action 4:

  • Action 5:

  • Action 6:

  • Action 7:

  • Action 8:

  • Action 9:

  • Action 10:

PART 5 - Sign-off

Initial Sign-off

  • The EVENT OWNER (e.g. Shift Supervisor) should sign to indicate that they have reviewed and accepted the report, including the actions and priorities. Any relevant comments can be added if required.

    The INVOLVED PERSON or EMPLOYEE SAFETY REPRESENTATIVE should sign to indicate that they have reviewed and accepted the report, including the actions and priorities. Any relevant comments can be added if required.

    The ######## or DELEGATED PERSON should sign to indicate that they have reviewed and accepted the report, including the actions and priorities. Any relevant comments can be added if required.

    The ########### should sign to indicate that they have reviewed and accepted the report, including the actions and priorities, and enter any relevant comments.

    The ###############should sign to indicate that they have reviewed and accepted the report, including the actions and priorities. Any relevant comments can be added if required. ######### sign-off is only required for events with an Actual Risk Ranking of Level 3 or greater.

    FINAL SIGN OFF – is only completed once reviewed by the ############to ensure verification of actions have been implemented and closed off before closing this investigation officially.

Supervisor Acceptance and Comments

  • Name:

  • Signature:

  • Date & Time:

  • Comments:

Involved Person Acceptance and Comments

  • Name:

  • Signature:

  • Date & Time:

  • Comments:

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

  • Name:

  • Signature:

  • Date:(dd/mm/yy)

  • Comments:

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

  • Name:

  • Signature:

  • Date:(dd/mm/yy)

  • Statutory Reporting Requirements:

  • Completed:

  • Corrective Actions Required:

  • Completed:

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

  • Review Date:

  • Comments:

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

  • Only required for Actual Level 3 risk ranking and above

  • Name:

  • Signature:

  • Date & Time:

  • Comments

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

  • Name:

  • Signature:

  • Date & Time:

  • Comments:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.