INCIDENT INVESTIGATION FORM

Privacy: This information will be stored and used in accordance with future incident prevention - Persons named on this form agree to stand in a court of law if requested

1.Location of Incident
Site Address Supervisor

2. Details of the incident being investigated

Name of Injured Person (If Applicable) Name of person who reported Incident

Incident Report Number:

Date of Incident
d d m m y y y y

Date of Report

3. Details of the Incident Investigation

Name of person completing this form Telephone Number Is this form being completed as part of an 'onsite' investigation Yes No Date Completed
d d m m y y y y

Email address Names of Investigation Team

Have any witnesses been interviewed as part of the Yes incident investigation? (attach witness statements if applicable.) No

Names of those interviewed

4. Description of Events
Describe the sequence of events that lead to the incident:

Describe the Sequence of events following the incident:

Describe the task being performed at the time of the incident

5. Risk Rating of Incident & Likelihood of Reoccurrence

Using the Two Variable Risk Matrix (Right):
Likelihood Label medium medium Low Low Low High medium medium Low Low Consequences (Severity) Label Neglible(I) Significant(II) Moderate (III) High High High medium medium Major (IV) Very High High High medium medium Catastophe (V) Very High Very High High High High

-Rate the consequences (Severity) Almost Certain (A) of the incident

Likely (B)

-Rate the likelihood of the incident Possible ( C ) occuring or reoccuring

Unlikely (D) Rare (E)

-Circle the resultant risk rating on the Risk Matrix

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Privacy: This information will be stored and used in accordance with future incident prevention - Persons named on this form agree to stand in a court of law if requested

5.1.Identify the behavioural causes of the Incident

Did any of the following behaviours contribute to the cause of the incident? (Choose below)
Performing task without authority Performing task at unsafe speed Performing task while affected by drugs/alcohol Perfoming task with improper work technique Performing task without PPE Performing task without correct PPE Failure to warn of hazard Failure to secure hazardous item Making safety device inoperable Distracting, teasing or abusing a person Using unsafe or tagged out equipment Using equipment in an unsafe manner Unsafe placement of equipment or objects Unsafe manual handling technique Unsafe Position or Posture Unsafe acts of others

Other (specify):
Not applicable

What are the management systems (procedural) deficiencies that led to the unsafe behaviours? (Choose below)
Inadequate Standard Operating Procedure/Policies Inadequate Supervision Inadequate Hazard Identification Inadequate assessment of risk Inadequate provision of PPE Inadequate Operator training Inadequate supervisor training Inadequate workplace inspection Inadequate equipment provided Inadequate design or construction of workplace Inadequate task or process design Unrealistic sheduling Other (Specify): Not applicable

5.2.Identify the Physical causes of the incident

Did any of the following conditions contribute to the cause of the incident? (Choose below)
Inadequate or absent gaurding Poor workstation design or layout Poor condition of equipment or objects Equipment or objects with unsafe design Unsafe storage or equipment or objects (housekeeping) Unsafe walking surfaces Unsafe lighting or glare Unsafe clothing or shoes Unsafe task or process Inadequate fire or explosion risk control Inadequate noise control Inadequate ventilation Inadequate temperature control Inadeqaute fall protection Inadequate signage or warning systems Inadeqautley controlled use of chemicals/substances

Other (specify):
Not applicable

What are the management systems (procedural) deficiencies that led to the unsafe conditions (Choose below)
Inadequate Standard Operating Procedure/Policies Inadequate Supervision Inadequate Hazard Identification Inadequate assessment of risk Inadequate provision of PPE Inadequate Operator training Inadequate supervisor training Inadequate workplace inspection Inadequate equipment provided Inadequate design or construction of workplace Inadequate task or process design Unrealistic sheduling Other (Specify): Not applicable

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Privacy: This information will be stored and used in accordance with future incident prevention - Persons named on this form agree to stand in a court of law if requested

6. Planned actions to prevent or reduce risk of re-occurrence

Planned actions to be taken to prevent or reduce risk of re-occurrence. Planned actions should address the identified causes of the incident.
1

Elimination Control

Substitution Control

Engineering Control

Administrative Control

PPE

Detail the actions

Completion Date
d d m m y y y y

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