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Seam Surveys Incident Report
Seam Surveys Incident Report
Lee Morse

Seam Surveys Incident Report

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Free Seam Surveys Incident Report Checklist

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Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location

  • Personnel

Incident Type

INCIDENT INFORMATION

  • Incident Number

Incident Type

  • Injury/Illness

Security Breach

  • Security Breach

Security breach type

  • Unauthorized entry to lease

  • Unauthorized access to restricted area

  • Unauthorized entry to plant

  • Unauthorized use of plant/equipment

  • Other

Asset Damage / Loss

  • Assets Damage/Loss

Asset Type

  • Mobile Plant

  • Fixed Plant

  • Auxiliary Plant

  • Light Vehicle

  • IT office computer equipment

  • Field Survey Equipment

  • Furniture

  • Tools

  • Building

  • Sundry Equipment

  • Item Description

  • Asset ID number

  • Make

  • Model number

  • Serial number

  • Year

  • Estimated repair/replacement cost

  • Damage/loss description

Community Heritage

  • Community/Heritage

  • Name of complainant

  • Contact telephone number

  • Address

Type of complaint

  • Dust

  • Water

  • Lighting

  • Noise

  • Odour

  • Visual

  • Heritage

  • Other

Nature of complaint

  • Change in landscape aesthetics

  • Reputation

  • Land use limitations - barriers, transportation, land values, sustainability

  • Affects on lifestyle - recreation etc

  • Cultural status / heritage sites

  • Other

Non-Compliance / Process

  • Non-Compliance / Process

Requirement Type

  • Legal Requirement

  • Client Requirement

  • Seam Requirement

  • Other

Non-compliance / procedure failure type

  • Process

  • Environment

  • Health

  • Quality

  • Safety

  • Heritage

  • Other

  • Non-compliance Description

  • Regulatory Authority

  • Source Of Obligation

Fire

  • Fire

Fuel type

  • Vegetation

  • Wood

  • Fuel - diesel

  • Fuel - petrol

  • Propane

  • Paper

  • Paint

  • Other

  • Description

Source of fire

  • Electrical

  • Lightning

  • Cutting/welding

  • Hot surface

  • Static electricity

  • Auto ignition

  • Instrumentation

  • Flame

  • Friction

  • Explosives

  • Location of fire

Method of extinction

  • Extinguisher

  • Blanket

  • Water

  • Other

  • Details

Environmental

  • Environmental

  • General Description

  • Flora

  • Injury / illness

  • Change in species diversity

  • Habit loss or modification

  • Introduction of exotic species

  • Death

  • Plant stress / reduction in plant growth

  • Fauna

  • Change in species diversity

  • Injury / illness

  • Habit loss or modification

  • Introduction of exotic species

  • Death

  • Surface Water

  • Contamination

  • Depletion of water source

  • Change in chemistry or properties

  • Temperature change

  • Groundwater

  • Contamination

  • Depletion of water source

  • Change in chemistry or properties

  • Temperature change

  • Change in pressure

  • Soil

  • Contamination

  • Compaction

  • Erosion

  • Air

  • Contamination

  • Other

  • Description

Source of impact

  • Emission of dust / particles

  • Spills of liquids

  • Emission of gas

  • Seepage of liquid

  • Clearing / excavation

  • Subsidence

  • Uncontrolled access / egress

  • Collision

  • Emission of light / noise

  • Winds

  • Rain

  • Other

Contaminant

  • Contaminant

  • Volume released

  • Volume recovered

Area

  • Area / distance covered

  • Description

  • Duration of incident

  • Estimated duration of impact

Actual Environmental Classification

  • Irreparable / long term

  • Major remedial action

  • Localized serious remedial action

  • Localized min remedial action

  • Little if any action

Hazards

  • Hazards

Near Miss

  • Near Miss

Non work related

  • Non work related

Details

Incident Details

  • Incident Date/Time

  • Reported Date/Time

  • Location

  • Reported by:

  • Reported to:

  • Supervisor Responsible

Personnel Involved

    Person

  • Name

  • Employee ID

  • Relationship to incident (e.g. Witness, Operator, Injured Person, Complainant)

  • Injured?

  • Head and Neck

  • Cranium

  • Ear

  • Eye

  • Face

  • Mouth

  • Neck

  • Nose

  • Upper limbs

  • Elbow

  • Lower arm

  • Upper arm

  • Shoulder

  • Wrist

  • Hand

  • Fingers

  • Trunk

  • Abdomen

  • Lower back

  • Upper back

  • Chest

  • Pelvis

  • Groin

  • Genitals

  • Lower limbs

  • Ankle

  • Lower leg

  • Upper leg

  • Hip

  • Knee

  • Foot

  • Toe

  • General

  • Circulatory system

  • Digestive system

  • Nervous system

  • Respiratory system

Nature of injury

  • Burns / Scals

  • Concussion with intracranial injuries

  • Contusions with intact skin surfaces

  • Dermatitis

  • Dislocation

  • Effects of radiation

  • Effects of toxic substances

  • Electric shock

  • Fracture

  • Heart and vascular disease

  • Infectious and parasitic disease

  • Internal injuries

  • Open wound

  • Sprains and strains

  • Thermal stress

  • Superficial injuries

  • Inflammation

  • Other

Source of Energy

  • Internal energy

  • Fall

  • Stepping on, sitting on

  • Rubbing or abrading

  • Grasping or touching

  • Striking against

  • Muscle effort

  • Other

  • External energy

  • Asphyxiating substance

  • Electrical energy

  • Mechanical

  • Radiation

  • Toxic substance

  • Attacks

  • Falling objects

  • Microbiological exposure

  • Sound / vibration

  • Corrosive substance

  • Flying objects

  • Thermal / heat

  • Other

  • Contaminant

Treatment Details

  • Treated by:

  • Treatment given:

  • Treatment date

Classification

  • Lost Time Injury (LTI)

  • Disabling Injury (DI)

  • Medical Treatment Injury (MTI)

  • First Aid Injury (FAI)

Description

Description

  • Brief Description

  • Detailed Description

  • Immediate Actions Taken After Incident

Incident Risk Rating

  • Likelihood 0 = Low 4 = High

  • Consequence 0 = Low 4 = High

SLAMS

  • SLAMS Available?

  • SLAMS Collected?

  • Amount of SLAMS

Client Reported Details

  • Client Name

  • Reported to client?

  • Date/Time Reported

Investigation

Investigation

  • Date investigation started

  • Date investigation completed

  • Investigation Leader

Event Sequence

  • Leading up to incident - what happened?

  • Following the incident - what happened?

Backup documentation

  • Backup documentation

    • Photographs

  • Photographs

  • Survey Drawing

  • Add media

  • Procedures

  • Add media

  • Work instructions

  • Add media

  • Statement

  • Add media

  • Other

  • Add media

Contributing Factors

  • Inadequate comms

  • Inadequate Training

  • Inadequate Supervision

  • Inadequate PPE

  • PPE Failed to protect.

  • Mistake: Lack of knowledge, unintentional

  • Slip/lapse of attention

  • Violation: Intentional deviation

  • Other

  • Explanation

  • Equipment contributing factors

  • Work area contributing factors

Procedure contributing factors

  • Exists but not followed

  • Exists but inadequate

  • Exists but unrealistic / impractical

  • Exists but not known

  • Does not exist

  • Formal risk assessment inadequate (JSA, SLAM etc)

  • Root cause summary

Corrective Actions

Corrective Actions

    Actions

  • Action title

  • Action Description

  • Assigned to

  • Date assigned

  • Due date

  • Priority 1 = Low 3 = High

Seam Surveys Incident Report
Lee Morse

Seam Surveys Incident Report

Use this Template
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.

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