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Form 23, Incident Investigation

The document details an incident investigation report form. The form collects information about an incident such as details, witnesses, root causes, and planned preventative actions. It aims to understand why incidents occur to prevent future occurrences.

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athul subash
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97 views4 pages

Form 23, Incident Investigation

The document details an incident investigation report form. The form collects information about an incident such as details, witnesses, root causes, and planned preventative actions. It aims to understand why incidents occur to prevent future occurrences.

Uploaded by

athul subash
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
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INCIDENT INVESTIGATION Report No :

REPORT FORM Date :

The level and complexity of investigations is relative to the seriousness of the incident.
This form is to be completed in the case of any Incident that had the potential to cause a Serious Harm Injury, and must be attached
to the initial BI Incident Report Form.

1. Incident Details:
Name of the Injured Name of Person Who
: :
Person (If Applicable) Reported the Incident
Location of Incident / Near
Date of Incident : : :
Incident Miss Report No

Details of the Incident as reported:

2. Details of Incident Investigation:


Incident Investigated by:

Name: Telephone Number:

Name: Telephone Number:

Name: Telephone Number:


Witness:
(Attach witness report as applicable)
Name: Telephone Number:

Name: Telephone Number:

3. Description of events:
Describe Sequence of events that lead to the incident:

Page 1 of 4 BERG/FO/HSE-23
INCIDENT INVESTIGATION Report No :

REPORT FORM Date :

Describe Sequence of events following the incident:

Why did it happen? (list the key factors & risks that contributed to the incident e.g. location, machinery,
procedures, people)

Incident Resulted in:


Fatality

Lost Time Incident No. of Lost Days :

Medical treatment Injury Hospitalised Not Hospitalised

Minor Injury / First Aid case First Aid given by :

Property Damage

Additional Information:

Page 2 of 4 BERG/FO/HSE-23
INCIDENT INVESTIGATION Report No :

REPORT FORM Date :

4. Root Cause Analysis:


4.1 Identify the behavioural causes of the Incident
Performing task without authority Distracting, teasing or abusing a person
Performing task at unsafe speed Using unsafe or tagged out equipment
Performing task while affected by drugs/alcohol Using equipment in an unsafe manner
Performing task with improper work technique Unsafe placement of equipment or objects
Performing task without Personal Protective Equip Unsafe manual handling technique
Performing task without correct Personal Protective Unsafe position or posture
Equip Unsafe acts of others
Failure to warn of hazard Horseplay
Failure to secure hazardous item Not applicable
Making safety device inoperable Other (specify):
Unsafe lifting

4.2 Identify the physical causes of the Incident (Unsafe Conditions)


Inadequate or absent guarding Improper / Lack of maintenance
Poor workstation design or layout Inadequate fire or explosion risk control
Poor condition of equipment or objects Inadequate noise control
Equipment or objects with unsafe design Inadequate ventilation
Unsafe storage of equipment/objects Inadequate temperature control
(housekeeping) Inadequate fall protection
Unsafe walking surfaces Inadequate signage or warning systems
Unsafe lighting or glare Inadequately controlled use of
Unsafe clothing or shoes chemicals/substances
Unsafe task or process Not applicable
Unsuitable equipment Other (specify):
Poor Cable Management

4.3 What are the management systems (procedural) deficiencies that led to the unsafe
conditions / acts?
Inadequate Standard Operating Inadequate workplace inspection
Procedures/policies Inadequate equipment provided
Inadequate supervision Inadequate design or construction of workplace
Inadequate hazard identification Inadequate task or process design
Inadequate assessment of risk Unrealistic scheduling
Inadequate provision of Personal Protective Equip Not applicable
Inadequate operator training Other (specify):
Inadequate supervisor training

Page 3 of 4 BERG/FO/HSE-23
INCIDENT INVESTIGATION Report No :

REPORT FORM Date :

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


By Completed
No. Action By Who
When Y/N
1
2
3
4
5
6
7 HSE alert required Yes/ No If Yes Alert No.
Additional Comments (Any additional information not covered above.)

Signed by (Investigation Team):


Signature : Signature : Signature :

Name : Name : Name :


Designation: Designation: Designation:
Date : Date : Date :

Investigation Report Reviewed by:

Attachments:
Photos Witness Statement Attendance Record
Driving Licence / Operator
Police Report
certificate Copy

Page 4 of 4 BERG/FO/HSE-23

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