Tetra Pak Incident Investigation Form

• Incident Investigation Title

• Document No.

• Client

• Location
  Address

• Personnel involved in the investigation

• Conducted on

  Date

• Prepared by

• Date and time of incident:

  Date

Incident summary:

• Name of injured person or person reporting the incident

• What type of incident occurred

  Select Fatality Permanent disability Lost time accident Medical treatment Restricted work Serious near miss Near Miss Environmental incident Property Damage

  • Fatality
  • Permanent disability
  • Lost time accident
  • Medical treatment
  • Restricted work
  • Serious near miss
  • Near Miss
  • Environmental incident
  • Property Damage

• What was the injury type

  Select Strain Laceration Bruising Fracture Amputation Burn Crush Electric shock None

  • Strain
  • Laceration
  • Bruising
  • Fracture
  • Amputation
  • Burn
  • Crush
  • Electric shock
  • None

• What was the injury category?

  Select Caught in pinch or nip Caught between or under Caught on Contact with electricity Contact with heat Contact with cold Contact with chemicals Contact with biological agents Contact with radiation Fall from height Fall on same level Struck by Struck against Electric shock Explosion Fire Ergonomics Noise Equipment failure No injury occurred

  • Caught in pinch or nip
  • Caught between or under
  • Caught on
  • Contact with electricity
  • Contact with heat
  • Contact with cold
  • Contact with chemicals
  • Contact with biological agents
  • Contact with radiation
  • Fall from height
  • Fall on same level
  • Struck by
  • Struck against
  • Electric shock
  • Explosion
  • Fire
  • Ergonomics
  • Noise
  • Equipment failure
  • No injury occurred

• What body part was affected

  Select Fingers or hand Arm Leg Foot Torso Head Eyes None

  • Fingers or hand
  • Arm
  • Leg
  • Foot
  • Torso
  • Head
  • Eyes
  • None

• Provide a summary of the incident, giving as much detail as possible

• Add photographs where possible

  Media

Task being conducted:

• Enter details of task being conducted:

Other persons involved / witnesses

• Name: Position: Location at time of incident:

Reference documentation:

• Procedure used?

• Work method statement used?

Immediate Actions:

• List immediate actions taken as a result of the incident:

Supplementary Actions:

• List actions taken to prevent recurrence:

Time line / Sequence of events:

• Describe the sequence of events from initial report and interviews:

• Draw the timeline if possible:

  Drawing

Contributing Factors: Task / Procedural

• Was a safe work procedure available?

  Yes

  No

  N/A

• Was a safe work procedure used?

  Yes

  No

  N/A

• Was a risk assessment conducted?

  Yes

  No

  N/A

• Were controls in place as per the RA / WMS?

  Yes

  No

  N/A

• Were appropriate tools and materials available?

  Yes

  No

  N/A

• Were they used?

  Yes

  No

  N/A

• Were personnel were trained to conduct the work?

  Yes

  No

  N/A

• Work Activity Briefing (WAB) was conducted noting all hazards?

  Yes

  No

  N/A

• The task remained unchanged from original job?

  Yes

  No

  N/A

Contributing Factors: Equipment / Substance

• All equipment was in good working order?

  Yes

  No

  N/A

• Was the equipment used as designed?

  Yes

  No

  N/A

• Equipment is regularly serviced?

  Yes

  No

  N/A

• Were pre-start checks conducted and correct?

  Yes

  No

  N/A

• Personnel were appropriately trained to operate equipment?

  Yes

  No

  N/A

• MSDS (material safety data sheet) are available on site?

  Yes

  No

  N/A

• All labels and signs in place and easy to read?

  Yes

  No

  N/A

• Appropriate PPE is available?

  Yes

  No

  N/A

• PPE was worn correctly?

  Yes

  No

  N/A

Contributing Factors: Environment / Behaviour

• Weather conditions were not a factor of the incident?

  Safe

  At Risk

  N/A

• Area was clean and tidy, poor housekeeper was not a factor?

  Safe

  At Risk

  N/A

• Was it too hot or too cold?

  Safe

  At Risk

  N/A

• Was it noisy?

  Safe

  At Risk

  N/A

• Was lighting adequate?

  Safe

  At Risk

  N/A

• Was fatigue evident?

  Safe

  At Risk

  N/A

• Was alcohol or another impairment evident?

  Safe

  At Risk

  N/A

• Was the task being rushed?

  Safe

  At Risk

  N/A

• Were workers complacent?

  Safe

  At Risk

  N/A

• Was poor vision a factor?

  Safe

  At Risk

  N/A

• Were health issues a factor?

  Safe

  At Risk

  N/A

• Workers were experienced and adequately supervised?

  Safe

  At Risk

  N/A

Other Contributing factors:

• List any other contributing factors:

• Add photos as required

  Media

Conclusions:

• Enter investigation conclusions:

Recommendations:

• Enter recommendations:

• Signature of investigating officer:

  Sign

• Signature of manager:

  Sign