SafetyInsights - Incident Investigation Report Form

• Incident Number

• Incident Date

  Date

• Site conducted

  Select

• Prepared by

• Business Area / Department

• Country / State

  Select NSW WA SA QLD NZ ACT VIC TAS

  • NSW
  • WA
  • SA
  • QLD
  • NZ
  • ACT
  • VIC
  • TAS

• Injured Person Name (if applicable)

• Gender

  Female

  Male

  Prefer Not to Answer

• Investigation Team Leader

Investigation Team Members

• Name

• Incident Classification

  Select Fatality Lost Time Injury Medical Treatment First Aid Injury Near Miss Non-Work-Related Occupational Illness Environmental No Injury

  • Fatality
  • Lost Time Injury
  • Medical Treatment
  • First Aid Injury
  • Near Miss
  • Non-Work-Related
  • Occupational Illness
  • Environmental
  • No Injury

• Was the Incident recorded?

  Yes

  No

  N/A

• Was Safety Team notified within 24 hours of the incident?

  Yes

  No

• Why was the safety team not notified within 24 hours?

• Did the worker require First Aid?

  No

  Yes

• Did the worker return to work without losing time?

  No

  Yes

• Incident Description (include sequence of events leading up to the incident and a summary of investigation facts and findings and photos if relevant)

• Select the type of incident (Mechanism of Injury)

  Select Falls, trips and slips Hitting an object Body Stressing Mental Stress Being hit by an object Vehicle incident Needle stick Chemicals and other substances Assault Occupational Violence and Aggressions Other

  • Falls, trips and slips
  • Hitting an object
  • Body Stressing
  • Mental Stress
  • Being hit by an object
  • Vehicle incident
  • Needle stick
  • Chemicals and other substances
  • Assault
  • Occupational Violence and Aggressions
  • Other

• Specify

• Nature of the Injuries

  Select Contusion, Bruising & Superficial Crushing Laceration or Open Wound Fractures Burn Soft Tissue Injuries Exposure to Substances Mental Disease Foreign body on external eye, in ear or nose Unspecified or Other Internal Organ Damage

  • Contusion, Bruising & Superficial Crushing
  • Laceration or Open Wound
  • Fractures
  • Burn
  • Soft Tissue Injuries
  • Exposure to Substances
  • Mental Disease
  • Foreign body on external eye, in ear or nose
  • Unspecified or Other
  • Internal Organ Damage

• Specify

• Body Location

  Select Abdomen Back Rear Chest Groin Head Head Rear Heel Left Heel Right Left Ankle Left Ear Left Ear Rear Left Elbow Left Elbow Rear Left Eye Left Foot Left Forearm Left Forearm Rear Left Hand Left Hand Rear Left Knee Left Knee Rear Left Lower Leg Left Lower Leg Rear Left Shoulder Left Shoulder Rear Left Thigh Left Thigh Rear Left Upper Arm Left Upper Arm Rear Left Wrist Left Wrist Rear Lower Back Rear Mouth Neck Neck Rear Nose Pelvis Pelvis Rear Right Ankle Right Ear Right Ear Rear Right Elbow Right Elbow Rear Right Eye Right Foot Right Forearm Right Forearm Rear Right Hand Right Hand Rear Right Knee Right Knee Rear Right Lower Leg Right Lower Leg Rear Right Shoulder Right Shoulder Rear Right Thigh Right Thigh Rear Right Upper Arm Right Upper Arm Rear Right Wrist Right Wrist Rear

  • Abdomen
  • Back Rear
  • Chest
  • Groin
  • Head
  • Head Rear
  • Heel Left
  • Heel Right
  • Left Ankle
  • Left Ear
  • Left Ear Rear
  • Left Elbow
  • Left Elbow Rear
  • Left Eye
  • Left Foot
  • Left Forearm
  • Left Forearm Rear
  • Left Hand
  • Left Hand Rear
  • Left Knee
  • Left Knee Rear
  • Left Lower Leg
  • Left Lower Leg Rear
  • Left Shoulder
  • Left Shoulder Rear
  • Left Thigh
  • Left Thigh Rear
  • Left Upper Arm
  • Left Upper Arm Rear
  • Left Wrist
  • Left Wrist Rear
  • Lower Back Rear
  • Mouth
  • Neck
  • Neck Rear
  • Nose
  • Pelvis
  • Pelvis Rear
  • Right Ankle
  • Right Ear
  • Right Ear Rear
  • Right Elbow
  • Right Elbow Rear
  • Right Eye
  • Right Foot
  • Right Forearm
  • Right Forearm Rear
  • Right Hand
  • Right Hand Rear
  • Right Knee
  • Right Knee Rear
  • Right Lower Leg
  • Right Lower Leg Rear
  • Right Shoulder
  • Right Shoulder Rear
  • Right Thigh
  • Right Thigh Rear
  • Right Upper Arm
  • Right Upper Arm Rear
  • Right Wrist
  • Right Wrist Rear

• Specify

• Select the behaviours that existed at the time of the incident

  Select Performed the task without authority Did not perform the task as per procedure Performed the tasks at an unsafe speed Used unsafe or tagged out equipment Performed the task while affected by drugs or alcohol Poor manual handling Performed the task without PPE Was aware of the hazard/risk but continued with the task Other

  • Performed the task without authority
  • Did not perform the task as per procedure
  • Performed the tasks at an unsafe speed
  • Used unsafe or tagged out equipment
  • Performed the task while affected by drugs or alcohol
  • Poor manual handling
  • Performed the task without PPE
  • Was aware of the hazard/risk but continued with the task
  • Other

• Specify

• Describe the conditions that existed at the time of the incident

  Select Inadequate guarding Inadequate emergency contol Poor design (e.g. workstation, tools) Inadequate noise control Poor condition of equipment, tools, PPE Inadequate ventilation/temperature control Poor storage of use of equipment, tools, chemicals PPE Inadequate equipment, tools, PPE Poor working surfaces Inadequate signange Poor lighting Poor housekeeping Poor task or process Other

  • Inadequate guarding
  • Inadequate emergency contol
  • Poor design (e.g. workstation, tools)
  • Inadequate noise control
  • Poor condition of equipment, tools, PPE
  • Inadequate ventilation/temperature control
  • Poor storage of use of equipment, tools, chemicals PPE
  • Inadequate equipment, tools, PPE
  • Poor working surfaces
  • Inadequate signange
  • Poor lighting
  • Poor housekeeping
  • Poor task or process
  • Other

• Specify

• Include the intermediate corrective actions taken

• Additional Comments

• Please refer to the risk matrix below

• 

• Likelihood

  Almost Certain

  Very Likely

  Possible

  Unlikely

  Rare

• Consequence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Risk Rating

  L

  M

  HM

  H

  VH

• Select the most appropriate root cause/s that would have contributed to the Direct causes identified

• Attitude/Behaviour

  Select Improper motivaton Inadequate work behaviour Individual actions of lack of actions Not following procedures

  • Improper motivaton
  • Inadequate work behaviour
  • Individual actions of lack of actions
  • Not following procedures

• Design

  Select Inadequate engineering Inadequate maintenance Inadequate tools Inadequate purchasing Wear and Tear

  • Inadequate engineering
  • Inadequate maintenance
  • Inadequate tools
  • Inadequate purchasing
  • Wear and Tear

• External Phenomenon

  Select Natural Disaster Not in operational control Insufficient lighting

  • Natural Disaster
  • Not in operational control
  • Insufficient lighting

• Lack of management control

  Select HSE management system failure Inadequate leadership/supervision Lack of adequate controls Lack of planning Lack of training No management review

  • HSE management system failure
  • Inadequate leadership/supervision
  • Lack of adequate controls
  • Lack of planning
  • Lack of training
  • No management review

• Lack of procedures

  Select Lack of knowledge Lack of skills Lack of work instructions

  • Lack of knowledge
  • Lack of skills
  • Lack of work instructions

• Other (specify)

Corrective Actions

• I take responsibility for ensuring all permanent corrective actions created above are completed and followed up to review effectiveness in prevent recurrence

• Account Manager Signature

  Sign

• Select date

  Date

Investigation Team Leaders Comments

• Further comments:

• Name

• HSE Advisor/National WHS Manager Signature

  Sign

• Date

  Date

• Comments