Easy assignments - Need in 6-8 Hours.Safety Management Systems

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:

FORMCHECKBOX Injury

FORMCHECKBOX Near Miss

FORMCHECKBOX MVI

FORMCHECKBOX Illness

FORMCHECKBOX Environmental

FORMCHECKBOX Property Damage

Activity / Job Task at time of incident:

Was there a JSA?

FORMCHECKBOX Yes FORMCHECKBOX No

Was the JSA signed by the supervisor?

FORMCHECKBOX Yes FORMCHECKBOX No

Did JSA identify the contributing hazard to the incident?

FORMCHECKBOX Yes FORMCHECKBOX No

Affected Individual:

Age:

Company:

Craft:

Classification:

FORMCHECKBOX Helper

FORMCHECKBOX Journeyman

FORMCHECKBOX Supervisor

FORMCHECKBOX Administrative

Gender:

FORMCHECKBOX Male FORMCHECKBOX 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:

FORMCHECKBOX Abrasion

FORMCHECKBOX Amputation

FORMCHECKBOX Asphyxia

FORMCHECKBOX Bites / Stings

FORMCHECKBOX Bruise / Contusion

FORMCHECKBOX Burn – Chemical

FORMCHECKBOX Burn – Thermal

FORMCHECKBOX Cold Related

FORMCHECKBOX Concussion

FORMCHECKBOX Contusion

FORMCHECKBOX Cut / Laceration

FORMCHECKBOX Dislocation

FORMCHECKBOX Electrical Shock

FORMCHECKBOX Foreign Body

FORMCHECKBOX Fracture

FORMCHECKBOX Hearing Loss

FORMCHECKBOX Heart Attack

FORMCHECKBOX Heat Related

FORMCHECKBOX Infection

FORMCHECKBOX Ingestion

FORMCHECKBOX Inhalation

FORMCHECKBOX Loss of Consciousness

FORMCHECKBOX Puncture Wound

FORMCHECKBOX Strain / Sprain

FORMCHECKBOX Stress / Anxiety

Body Part:

FORMCHECKBOX Abdomen

FORMCHECKBOX Back

FORMCHECKBOX Buttocks

FORMCHECKBOX Chest

FORMCHECKBOX Ear (external)

FORMCHECKBOX Eye

FORMCHECKBOX Face

FORMCHECKBOX Finger / Thumb

FORMCHECKBOX Foot / Ankle

FORMCHECKBOX Forearm

FORMCHECKBOX Groin

FORMCHECKBOX Hand / Wrist

FORMCHECKBOX Hearing

FORMCHECKBOX Knee

FORMCHECKBOX Lower Leg

FORMCHECKBOX Mouth

FORMCHECKBOX Neck

FORMCHECKBOX Nervous System

FORMCHECKBOX Nose

FORMCHECKBOX Organs

FORMCHECKBOX Respiratory

FORMCHECKBOX Scalp

FORMCHECKBOX Shoulder

FORMCHECKBOX Thigh

FORMCHECKBOX Toe(s)

FORMCHECKBOX Upper Arm

Equipment Involved:

FORMCHECKBOX Aerial Platform

FORMCHECKBOX Bicycles

FORMCHECKBOX Crane

FORMCHECKBOX Earth Moving

FORMCHECKBOX Electrical

FORMCHECKBOX Forklift

FORMCHECKBOX Hand Tools

FORMCHECKBOX Laboratory

FORMCHECKBOX Ladders

FORMCHECKBOX Motor Vehicles

FORMCHECKBOX Power Tools

FORMCHECKBOX Process

FORMCHECKBOX Rigging

FORMCHECKBOX Scaffolding

FORMCHECKBOX Welding / Compressors

Equipment No.:

Equipment Owner:

Injury Classification:

FORMCHECKBOX Exam Only

FORMCHECKBOX OSHA Recordable

FORMCHECKBOX Restricted Work

FORMCHECKBOX First Aid

FORMCHECKBOX Personal Illness/Pre-existing

FORMCHECKBOX Lost Time Accident

Treatment Description:

FORMCHECKBOX Butterfly Strips

FORMCHECKBOX Cast

FORMCHECKBOX Clean / Bandage

FORMCHECKBOX Extraction

FORMCHECKBOX Fluid Draining

FORMCHECKBOX Flushing

FORMCHECKBOX Hot / Cold Therapy

FORMCHECKBOX Non-Prescription

FORMCHECKBOX Physiotherapy

FORMCHECKBOX Prescription

FORMCHECKBOX Splint

FORMCHECKBOX Sutures / Splints

FORMCHECKBOX Tetanus Shot

FORMCHECKBOX 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

FORMCHECKBOX Poor decision making or lack of judgment

FORMCHECKBOX Exposure to elevation / heights

FORMCHECKBOX Negative attitude towards HSE / lack of belief

FORMCHECKBOX Inadequate illumination

FORMCHECKBOX Improper lifting

FORMCHECKBOX Inadequate housekeeping

FORMCHECKBOX Inattention or distraction

FORMCHECKBOX Slippery surfaces

FORMCHECKBOX Horseplay

FORMCHECKBOX Lack of signage or poor marking

FORMCHECKBOX Improper reaction to change

FORMCHECKBOX Abnormal biological presence

FORMCHECKBOX Victim of another person's actions

FORMCHECKBOX Inadequate ventilation

FORMCHECKBOX Personal goals vs. safety goals

FORMCHECKBOX Inadequate/defective work surfaces

FORMCHECKBOX Taking unsafe position (line of fire)

Process Hazards

Tools or Equipment Use

FORMCHECKBOX Fire and explosion hazards

FORMCHECKBOX Operating equipment w/o authority/req. training

FORMCHECKBOX Deficient labeling

FORMCHECKBOX Improper placement of tool or equipment

FORMCHECKBOX Process system/equipment failure

FORMCHECKBOX Unsafe mixing of chemicals

FORMCHECKBOX Inadequate isolation of equipment

FORMCHECKBOX Disabling guards or warning systems

FORMCHECKBOX Unsegregated hazardous substances

FORMCHECKBOX Using known defective tool or equipment

FORMCHECKBOX Excess or uncontrolled hazard(s)

FORMCHECKBOX Loss of control of tool or equipment

Tools & Equipment Condition

FORMCHECKBOX Using tool or equipment improperly

FORMCHECKBOX Defective tool or equipment

FORMCHECKBOX Improper use or failure to use proper PPE

FORMCHECKBOX Insufficient or lack of anchor points

FORMCHECKBOX Using improper or modified tool or equipment

FORMCHECKBOX Improperly prepared tool or equipment

Procedures implementation

FORMCHECKBOX Inadequate tool/equipment for task

FORMCHECKBOX JHA not followed

FORMCHECKBOX Maintenance inadequate

FORMCHECKBOX Standards/ Procedures/ Guidelines not followed

Protective Defenses

FORMCHECKBOX Conscious risk taking (by group or individual)

FORMCHECKBOX Inadequate guards/protective devices

FORMCHECKBOX Improper loading of materials or equipment

FORMCHECKBOX Defective guards/protective devices

FORMCHECKBOX Working too quickly or in a hurry

FORMCHECKBOX Inadequate warning systems

FORMCHECKBOX Defective warning systems

FORMCHECKBOX Defective PPE

Weather conditions

FORMCHECKBOX Extreme temperatures

FORMCHECKBOX Abnormal wind conditions

FORMCHECKBOX Precipitation, fog, etc.

Indirect Cause

People Factors

Physical Capabilities

Physiological

FORMCHECKBOX Fatigue

FORMCHECKBOX Mental fatigue due to lack of rest

FORMCHECKBOX Substance sensitivities or allergies

FORMCHECKBOX Atmospheric pressure variation

FORMCHECKBOX Inability to use/wear PPE

FORMCHECKBOX Incapacitated (health conditions)

FORMCHECKBOX Overexertion

FORMCHECKBOX Emotional overload

FORMCHECKBOX Self medication, prescription drug use

FORMCHECKBOX Mental task load or speed

FORMCHECKBOX Alcohol or drug abuse

FORMCHECKBOX Routine vigilance, monotony

Mental Capabilities

FORMCHECKBOX Conflicting demands, frustration

FORMCHECKBOX Fears and phobias

FORMCHECKBOX Emotional disturbance / stress

FORMCHECKBOX Poor judgment

Execution Factors

Engineering / Design

Skill & Knowledge

FORMCHECKBOX Unsafe design

FORMCHECKBOX Lack of experience by worker(s)

FORMCHECKBOX Engineering or design related failure

FORMCHECKBOX Infrequently performed task

FORMCHECKBOX Improper materials used, specified

FORMCHECKBOX Inadequate training, knowledge or skill

FORMCHECKBOX Poor ergonomic design

Project level execution

Tools & Equipment Provision

FORMCHECKBOX Inadequate performance measurement, evaluation and feedback

FORMCHECKBOX Inadequate assessment of needs

FORMCHECKBOX Inadequate job placement (wrong worker assigned to the job

FORMCHECKBOX Inadequate availability of tools / equipment

FORMCHECKBOX Unclear or conflicting reporting relationships

FORMCHECKBOX Inadequate maintenance of tools / equipment

FORMCHECKBOX Improper delegation

Communication

FORMCHECKBOX Inadequate accident reporting or investigation

FORMCHECKBOX Unclear or incomplete instructions, to injured

FORMCHECKBOX Deficient review of JHA / JSA by supervisor

FORMCHECKBOX Unclear or incomplete instructions between others (supervisors, contractors, clients, etc.)

FORMCHECKBOX Lack of coaching or monitoring

FORMCHECKBOX Non-standard terms, phrases, etc.

FORMCHECKBOX Lack of supervisory task/job knowledge

FORMCHECKBOX Deficient handover process (between shifts, workers, etc.)

FORMCHECKBOX Language barriers

Root Cause

Management Aspects

Program/System Aspects

Resource Management

Work Standards / Procedures

FORMCHECKBOX Inadequate evaluation of change in work scope / plans

FORMCHECKBOX Inadequate requirements for PPE

FORMCHECKBOX Insufficient communication of safety expectations

FORMCHECKBOX Inadequate reference documents, directives, manuals

FORMCHECKBOX Shortage of resources to perform the task safely

FORMCHECKBOX Inadequate regulations or procedures

FORMCHECKBOX Lack of evaluation of hazards or mitigation options

Risk Evaluation

FORMCHECKBOX Lack of clear roles and responsibilities

FORMCHECKBOX Inadequate job safety/hazard analysis

FORMCHECKBOX Inadequate job placement- supervisory level

FORMCHECKBOX Failure in Management of Change

FORMCHECKBOX Lack of reinforcement of proper behaviors or lack of disciplinary actions

FORMCHECKBOX Risk evaluation not performed

FORMCHECKBOX Cultural issues not recognized, understood, respected, etc.

Task Planning

Leadership

FORMCHECKBOX JHA not developed

FORMCHECKBOX Improper performance rewards (Actions other than safety being rewarded)

FORMCHECKBOX JHA written but not reviewed by all

FORMCHECKBOX Lack of or ineffective safety incentives

FORMCHECKBOX JHA did not involve all workers

FORMCHECKBOX Avoided confronting client or others about safety

FORMCHECKBOX JHA did not address all task steps

FORMCHECKBOX Inappropriate peer pressure

FORMCHECKBOX JHA did not address all hazards

FORMCHECKBOX Lack of lessons learned sharing and implementing

Training

FORMCHECKBOX Inadequate performance feedback

FORMCHECKBOX Lack of initial orientation

FORMCHECKBOX Failure to follow recommendations of HSE personnel

FORMCHECKBOX Inadequate orientation provided

FORMCHECKBOX Failure to implement corrective actions

FORMCHECKBOX Lack of required training

FORMCHECKBOX Inadequate attempt to save time, money, labor, etc

FORMCHECKBOX Inadequate training provided

Contractors & Subcontractor Mgt.

FORMCHECKBOX Inadequate refresher / update training

FORMCHECKBOX Inadequate safety specification / contract clauses

Inspection and Audit program

FORMCHECKBOX Inadequate receiving, inspection, acceptance of work, equip.

FORMCHECKBOX Failure to perform required inspections / audits

FORMCHECKBOX Hazard not identified on audit

FORMCHECKBOX 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