• Date and time of incident:

Incident summary:

  • Name of injured person or person reporting the incident

  • What type of incident occurred

  • What was the injury type

  • What was the injury category?

  • What body part was affected

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

  • Add photographs where possible

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:

Contributing Factors: Task / Procedural

  • Was a safe work procedure available?

  • Was a safe work procedure used?

  • Was a risk assessment conducted?

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

  • Were appropriate tools and materials available?

  • Were they used?

  • Were personnel were trained to conduct the work?

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

  • The task remained unchanged from original job?

Contributing Factors: Equipment / Substance

  • All equipment was in good working order?

  • Was the equipment used as designed?

  • Equipment is regularly serviced?

  • Were pre-start checks conducted and correct?

  • Personnel were appropriately trained to operate equipment?

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

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

  • Appropriate PPE is available?

  • PPE was worn correctly?

Contributing Factors: Environment / Behaviour

  • Weather conditions were not a factor of the incident?

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

  • Was it too hot or too cold?

  • Was it noisy?

  • Was lighting adequate?

  • Was fatigue evident?

  • Was alcohol or another impairment evident?

  • Was the task being rushed?

  • Were workers complacent?

  • Was poor vision a factor?

  • Were health issues a factor?

  • Workers were experienced and adequately supervised?

Other Contributing factors:

  • List any other contributing factors:

  • Add photos as required

Conclusions:

  • Enter investigation conclusions:

Recommendations:

  • Enter recommendations:

  • Signature of investigating officer:

  • Signature of manager:

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