Title Page

  • Location

  • Conducted on

  • Prepared by

  • Reference number (Generated from Issue)

  • Incident Summary

Investigation of Accident

Interim Containment

  • Describe what has been put in place to stop the issue from escalating?

  • What corrective actions have been implemented to improve the human factor cause of this accident?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the materials used in this accident?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the measurement aspects of this accident?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the equipment used in this accident?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the process related to this accident?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the environment associated with this accident?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

Verify and Determine the root cause

  • You can use the simple Ishikawa (Fishbone) principle to determine a potential root cause as a brain storming tool with the colleagues or the 5 Why process

    Screenshot 2022-03-09 at 15.01.40.png
  • Which root cause analysis will you use?

  • 5 Why Analysis (click the green + button to complete)
  • What is the problem you are going to root cause analyse

  • Why?

  • Why?

  • Why?

  • Why?

  • Why?

  • As determined by the 5Why above, what are the Immediate/Direct Causes (circumstances that immediately precede the accident)

  • As determined by the 5 Why above, what is the Basic/Root Cause for the accident?

  • What was the Person/ Human Factor Root cause?

  • What is the job/ system factor of the root cause

Prevent Recurrence

  • Has the problem has reoccurred since implementation of all actions.

  • The root cause analysis should be reviewed and additional prevenatative actions implemented

  • Does a risk assessment exist for this task?

  • Has the risk assessment been reviewed?

  • The risk assessment must be reviewed before closing this investigation

  • What is the risk assessment reference?

  • A risk assessment must be devised and communicated. Please raise an action to complete an assessment as required in QSHE SOP 006

    risk.JPG
  • Has the procedure/ process been updated?

  • Have the results and improvements been communicated to all affected persons?

  • Has the corrective action been witnessed?

  • If the answer is yes to all of the above in this section, then the investigation is ready to be closed

Sign off

End of Investigation - Sign off

  • Team Leader sign off:

  • Completion Date

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.