TDE HS Form 13.0 Incident Investigation

• Document No.

• Document No. of Incident Report

• Form Completed by

INCIDENT DETAILS SUMMARY

• Incident Location / Site

• Incident Date / Time

  Date

• Incident Type

  Select Property damage Close call (no injury or damage) Injury not requiring treatment Injury requiring on site first aid Injury requiring medical treatment Work-related health event Fatality

  • Property damage
  • Close call (no injury or damage)
  • Injury not requiring treatment
  • Injury requiring on site first aid
  • Injury requiring medical treatment
  • Work-related health event
  • Fatality

• Detail all relevant information pertaining to the workers, equipment, environment, and processes. Describe the sequence of events leading up to, during, and following the incident.

• Additional Photos

  Media

• Is this a notifiable event?

  Yes

  No

  Not Applicable

• Has Worksafe been notified?

  Yes

  No

  Not Applicable

• Notification reference number

INCIDENT CAUSE ANALYSIS

• You can use the incident cause analysis guide (in Google Drive) to help you identify the immediate and root causes

  

• Identify the IMMEDIATE CAUSES.
  These are the physical factors that contributed to the incident and may represent hazards that were not recognised or controlled. These are the surface issues - though they may need to be rectified immediately, addressing these issues won't prevent similar incidents in the future.

Immediate Cause / Contributing Factor

• Describe

• Identify the ROOT CAUSES.
  These are the factors at the heart of what caused the the incident; they are usually related to organisation culture, behaviours, systems and procedures. These are the critical issues to address to prevent similar incidents in the future. There will nearly always be multiple root causes.

Root Cause

• Describe

CORRECTIVE AND PREVENTATIVE ACTIONS

• Determine the corrective actions required for each immediate cause and root cause.
  Click the Add Action button and type a short title for the action. The click on the paperclip icon and choose 'add action' to link an action to this investigation, describe what needs to be done, designate the person responsible and set a priority and due date.

Action

• Action Title

REPORTING

• This investigation must be emailed to all directors.

• Please sign to indicate that you have completed the investigation to the best of your ability and will send the report to the directors.

  Sign