Easy assignments - Need in 6-8 Hours.Safety Management Systems
Incident Investigation Form
Date of Incident: | | Time of Incident: | | ||||||||||
Investigation Date: | | Investigation Time: | | ||||||||||
Brief Description of Incident: | | ||||||||||||
Responsible Supervisor: | | Length of time as supervisor: | | ||||||||||
Project Name: | | | | ||||||||||
Location of Incident: | | ||||||||||||
Incident Type: | Injury Near Miss | MVI Illness | Environmental Property Damage |
Activity / Job Task at time of incident: | | ||||
| | ||||
Was there a JSA? | Yes No | Was the JSA signed by the supervisor? | Yes No | ||
Did JSA identify the contributing hazard to the incident? | Yes No |
Affected Individual: | Age: | |||
Company: | Craft: | |||
Classification: | Helper Journeyman | Supervisor Administrative | Gender: | Male Female |
Persons Involved in the Incident | Craft | Company | Time with Company | |||
Investigation Team (Please Print Full Names) | ||||||
Name | Company | Employee No. | Craft | |||
Nature of Injury: | Abrasion | Amputation | Asphyxia | Bites / Stings | ||||||||
Bruise / Contusion | Burn – Chemical | Burn – Thermal | Cold Related | |||||||||
Concussion | Contusion | Cut / Laceration | Dislocation | |||||||||
Electrical Shock | Foreign Body | Fracture | Hearing Loss | |||||||||
Heart Attack | Heat Related | Infection | Ingestion | |||||||||
Inhalation | Loss of Consciousness | Puncture Wound | Strain / Sprain | |||||||||
Stress / Anxiety | ||||||||||||
Body Part: | Abdomen | Back | Buttocks | Chest | ||||||||
Ear (external) | Eye | Face | Finger / Thumb | |||||||||
Foot / Ankle | Forearm | Groin | Hand / Wrist | |||||||||
Hearing | Knee | Lower Leg | Mouth | |||||||||
Neck | Nervous System | Nose | Organs | |||||||||
Respiratory | Scalp | Shoulder | Thigh | |||||||||
Toe(s) | Upper Arm | |||||||||||
Equipment Involved: | Aerial Platform | Bicycles | Crane | |||||||||
Earth Moving | Electrical | Forklift | ||||||||||
Hand Tools | Laboratory | Ladders | ||||||||||
Motor Vehicles | Power Tools | Process | ||||||||||
Rigging | Scaffolding | Welding / Compressors | ||||||||||
Equipment No.: | ||||||||||||
Equipment Owner: | ||||||||||||
Injury Classification: | Exam Only | OSHA Recordable | Restricted Work | |||||||||
First Aid | Personal Illness/Pre-existing | Lost Time Accident | ||||||||||
Treatment Description: | Butterfly Strips | Cast | Clean / Bandage | Extraction | ||||||||
Fluid Draining | Flushing | Hot / Cold Therapy | Non-Prescription | |||||||||
Physiotherapy | Prescription | Splint | Sutures / Splints | |||||||||
Tetanus Shot | Other: | |||||||||||
Treatment Facility: |
Environmental | |||
Substance: | Volume: |
Description of Incident: |
Immediate Corrective Action |
Prevention from Reoccurance: |
Causal Analysis | |
Direct Cause | |
Unsafe Acts | Unsafe Conditions |
Individual behavior/attitude | Workplace Hazards |
Poor decision making or lack of judgment | Exposure to elevation / heights |
Negative attitude towards HSE / lack of belief | Inadequate illumination |
Improper lifting | Inadequate housekeeping |
Inattention or distraction | Slippery surfaces |
Horseplay | Lack of signage or poor marking |
Improper reaction to change | Abnormal biological presence |
Victim of another person's actions | Inadequate ventilation |
Personal goals vs. safety goals | Inadequate/defective work surfaces |
Taking unsafe position (line of fire) | Process Hazards |
Tools or Equipment Use | Fire and explosion hazards |
Operating equipment w/o authority/req. training | Deficient labeling |
Improper placement of tool or equipment | Process system/equipment failure |
Unsafe mixing of chemicals | Inadequate isolation of equipment |
Disabling guards or warning systems | Unsegregated hazardous substances |
Using known defective tool or equipment | Excess or uncontrolled hazard(s) |
Loss of control of tool or equipment | Tools & Equipment Condition |
Using tool or equipment improperly | Defective tool or equipment |
Improper use or failure to use proper PPE | Insufficient or lack of anchor points |
Using improper or modified tool or equipment | Improperly prepared tool or equipment |
Procedures implementation | Inadequate tool/equipment for task |
JHA not followed | Maintenance inadequate |
Standards/ Procedures/ Guidelines not followed | Protective Defenses |
Conscious risk taking (by group or individual) | Inadequate guards/protective devices |
Improper loading of materials or equipment | Defective guards/protective devices |
Working too quickly or in a hurry | Inadequate warning systems |
Defective warning systems | |
Defective PPE | |
Weather conditions | |
Extreme temperatures | |
Abnormal wind conditions | |
Precipitation, fog, etc. |
Indirect Cause | |
People Factors | |
Physical Capabilities | Physiological |
Fatigue | Mental fatigue due to lack of rest |
Substance sensitivities or allergies | Atmospheric pressure variation |
Inability to use/wear PPE | Incapacitated (health conditions) |
Overexertion | Emotional overload |
Self medication, prescription drug use | Mental task load or speed |
Alcohol or drug abuse | Routine vigilance, monotony |
Mental Capabilities | Conflicting demands, frustration |
Fears and phobias Emotional disturbance / stress | |
Poor judgment | |
Execution Factors | |
Engineering / Design | Skill & Knowledge |
Unsafe design | Lack of experience by worker(s) |
Engineering or design related failure | Infrequently performed task |
Improper materials used, specified | Inadequate training, knowledge or skill |
Poor ergonomic design | |
Project level execution | Tools & Equipment Provision |
Inadequate performance measurement, evaluation and feedback | Inadequate assessment of needs |
Inadequate job placement (wrong worker assigned to the job | Inadequate availability of tools / equipment |
Unclear or conflicting reporting relationships | Inadequate maintenance of tools / equipment |
Improper delegation | Communication |
Inadequate accident reporting or investigation | Unclear or incomplete instructions, to injured |
Deficient review of JHA / JSA by supervisor | Unclear or incomplete instructions between others (supervisors, contractors, clients, etc.) |
Lack of coaching or monitoring | Non-standard terms, phrases, etc. |
Lack of supervisory task/job knowledge | Deficient handover process (between shifts, workers, etc.) |
Language barriers |
Root Cause | |
Management Aspects | Program/System Aspects |
Resource Management | Work Standards / Procedures |
Inadequate evaluation of change in work scope / plans | Inadequate requirements for PPE |
Insufficient communication of safety expectations | Inadequate reference documents, directives, manuals |
Shortage of resources to perform the task safely | Inadequate regulations or procedures |
Lack of evaluation of hazards or mitigation options | Risk Evaluation |
Lack of clear roles and responsibilities | Inadequate job safety/hazard analysis |
Inadequate job placement- supervisory level | Failure in Management of Change |
Lack of reinforcement of proper behaviors or lack of disciplinary actions | Risk evaluation not performed |
Cultural issues not recognized, understood, respected, etc. | Task Planning |
Leadership | JHA not developed |
Improper performance rewards (Actions other than safety being rewarded) | JHA written but not reviewed by all |
Lack of or ineffective safety incentives | JHA did not involve all workers |
Avoided confronting client or others about safety | JHA did not address all task steps |
Inappropriate peer pressure | JHA did not address all hazards |
Lack of lessons learned sharing and implementing | Training |
Inadequate performance feedback | Lack of initial orientation |
Failure to follow recommendations of HSE personnel | Inadequate orientation provided |
Failure to implement corrective actions | Lack of required training |
Inadequate attempt to save time, money, labor, etc | Inadequate training provided |
Contractors & Subcontractor Mgt. | Inadequate refresher / update training |
Inadequate safety specification / contract clauses | Inspection and Audit program |
Inadequate receiving, inspection, acceptance of work, equip. | Failure to perform required inspections / audits |
Hazard not identified on audit | |
Missing program element not identified on inspection / audit |
INCIDENT INVESTIGATION STATEMENT | |||||||||||
Name: | Age: | ||||||||||
Employee ID#: | Date: | Time: | |||||||||
Time in Complex: | Time with Company: | ||||||||||
Time in Craft: | Position: | ||||||||||
Immediate Supervisor: | |||||||||||
Phone No.: | |||||||||||
Temporary Address: | Permanent Address: | ||||||||||
Location at the time of the Incident: | |||||||||||
Describe, to the best of your knowledge, what happened just before, during, and just after the incident: | |||||||||||
HSE Use Only: | Witness | Injured | Non-Injured |