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Incident Investigation Report FORM

This incident report form documents a workplace incident that occurred without lost time. The incident involved workers working on heights without wearing full body harnesses. As a result of the incident, corrective actions were taken including conducting toolbox safety meetings, requiring workers to always wear full body harnesses when working at heights, assigning safety watchmen to monitor work areas, and ensuring fire extinguishers are visible. The report identifies the substandard actions of failing to wear personal protective equipment as the cause of the incident.

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luishorquia
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85 views

Incident Investigation Report FORM

This incident report form documents a workplace incident that occurred without lost time. The incident involved workers working on heights without wearing full body harnesses. As a result of the incident, corrective actions were taken including conducting toolbox safety meetings, requiring workers to always wear full body harnesses when working at heights, assigning safety watchmen to monitor work areas, and ensuring fire extinguishers are visible. The report identifies the substandard actions of failing to wear personal protective equipment as the cause of the incident.

Uploaded by

luishorquia
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 Form__________

( O ) INCIDENT (Please see entries with *) ( ) ACCIDENT (Please see all entries) ( ) NEARMISS (Please see entries with*)
without Lost Time with Lost Time

DATE OF INCIDENT: TIME: DATE REPORTED: TIME:

*1. GROUP OR DIVISION *2. NAME *3. OCCUPATION *4. LOCATION OF INCIDENT

DAMAGE IN
PERSON
MATERIALS/ EQUIPMENT/ENVIRONMENT
5. DID THE INCIDENT/ACCIDENT RESULT IN 10. DID THE INCIDENT/ACCIDENT INVOLVE DAMAGE
OF PROPERTY, ENVIRONMENT OR EQUIPMENT
PERSONAL INJURY ( ) ILLNESS ( ) ( ) YES ( O ) NO
CONFINEMENT ( ) DEATH ( ) TO WHAT? (Provide Details)

(For confinement, please fill out the following details) _________________________________________


MEDICAL FACILITIES________________________
DOCTOR’S NAME ________________________

6. NATURE OF INJURY 7. LOST DAYS 11.EQUIPMENT 12. ENVIRONMENT


OR ILLNESSES COST/DAMAGE

ESTIMATE COST
ACTUAL
8. PART OF THE BODY *9. SUPERVISING ENGINEER *13. PERSON MOST CONTROL OF INFLICTING ITEM

14. WAS FIRST AID RENDERED?

( ) YES ( O ) NO BY WHOM __________________________________

15. DESCRIBE HOW THE EVENT OCCURRED


 Workers not wearing Full body harness while working on heights.
 No safety watchmen under the works area.
 Fire Extinguisher not visible in the ground area.

*16. ACTION TO THE SAID INCIDENT


 Conduct Toolbox meeting every morning before the star of the work to remind all workers to always be attentive
regarding safety practices.
 All workers must wear full body harness at all time while working on heights.
 Watchmen must be always monitoring the ground while workers are on site.
 Fire Extinguishers must be always visible to the area all the time.
*17. WHAT SUBSTANDARD ACTIONS AND CONDITIONS CAUSED OR COULD HAVE CAUSED THE EVENT

Incident Investigation Report Form__________


CODING OF IMMEDIATE CAUSES: CHECK ALL APPLICABLE

Substandard actions such as using defective equipment and improper lifting are common examples. Substandard conditions
such as housekeeping, restricted access and poor illumination are also common examples. Identify all those which had
some bearing on the incident, then ask the question – WHY?
SUBSTANDARD ACTIONS SUBSTANDARD CONDITIONS

 1. Operating equipment w/o authority  1. Inadequate guards or barriers


 2. Failure to warn  2. Inadequate or improper protective equipment
 3. Failure to secure  3. Defective tools, equipment, or materials
 4. Operating at improper speed  4. Congestion or restricted action
 5. Making safety devices inoperable  5. Inadequate warning system
 6. Removing safety devices  6. Fire and explosion hazards
 7. Using defective equipment  7. Poor housekeeping; disorder
 8. Using equipment/ materials improperly  8. Hazardous environmental conditions; gases,
 9. Failing to PPE properly dusts, smokes, fumes, vapors
 10. Improper loading  9. Noise exposures
 11. Improper placement  10. Radiation exposures
 12. Improper lifting  11. High or low temperature exposures
 13. Improper position for task  12. Inadequate or excess illumination
 14. Servicing equipment in operation  13. Inadequate ventilation
 15. Horseplay
 16. Under influence of alcohol and/or other drugs
Details of the substandard act/ condition:
Failed to wear PPE (full body harness).

*18. BASIC CAUSE

There are two types of basic causes classed as personal factors such as capability, knowledge and stress and Job Factors
such as supervision, instructions, maintenance, etc.
PERSONAL FACTORS JOB FACTOR

 1. Inadequate capability  1. Inadequate leadership/ evaluation


 2. Lack of knowledge  2. Inadequate engineering
 3. Lack of Skill  3. Inadequate purchasing
 4. Stress  4. Inadequate tools/equipment
 5. Improper Motivation  5. Inadequate work standards
 6. Previous Practices  6. Wear and tear
 7. Attitude

Details of the substandard act/ condition:


__________________________________________________________________
________________________________________________________________

*19. REMEDIAL ACTIONS (CORRECTIONS) : What has and/or should be done to control the causes listed

RISK ASSESMENT for remedial actions taken


*20. CORRECTIVE ACTION TAKEN AT WORK SITE
 Always remind all workers to wear full body harness while working on heights.
 Make sure that the watchmen is always in the work area.
 Place fire extinguisher in visible position in the area.

RISK ASSESMENT for CORRECTIVE ACTION


Incident Investigation Report Form__________

PREPARED BY REVIEWED BY APPROVED BY

_________________ _______ ____________


Project Engineer in Charge Safety Officer PROJECT MANAGER

Follow-up Action
Proposed remedial action verified: Date: By: Signature:
__________
DMR
Proposed corrective action verified: Date: By: Signature:
_________
DMR
Other comments:

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