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SCAT Incident Investigation Form

The SCAT Incident Investigation Form is a structured document used to report and analyze incidents, including details such as date, time, location, and type of incident. It requires identification of immediate causes, root causes, contributing factors, and corrective actions to prevent future occurrences. The form also includes sections for follow-up and sign-off by responsible personnel.

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24 views

SCAT Incident Investigation Form

The SCAT Incident Investigation Form is a structured document used to report and analyze incidents, including details such as date, time, location, and type of incident. It requires identification of immediate causes, root causes, contributing factors, and corrective actions to prevent future occurrences. The form also includes sections for follow-up and sign-off by responsible personnel.

Uploaded by

roxyellis
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SCAT Incident Investigation Form

1. Basic Incident Information


**Date of Incident**
**Time**
**Location**
**Reported By**
**Date Reported**
**Investigation Conducted By**
**Incident Type**: ☐ Injury ☐ Property Damage ☐ Environmental ☐ Near Miss ☐ Other:
_______

2. Incident Description
Provide a clear and concise description of what happened.

3. Immediate (Direct) Causes


Identify unsafe acts and unsafe conditions that directly led to the incident.

Unsafe Acts:

 ☐ Operating equipment without authority


 ☐ Failure to secure / warn / follow procedure
 ☐ Operating at improper speed
 ☐ Making safety devices inoperative
 ☐ Using defective equipment
 ☐ Improper lifting or handling
 ☐ Failure to use PPE
 ☐ Horseplay
 ☐ Other: ________________________

Unsafe Conditions:

 ☐ Inadequate guarding or protection


 ☐ Poor housekeeping
 ☐ Inadequate warning system
 ☐ Inadequate ventilation
 ☐ Defective tools or equipment
 ☐ Poor workstation layout
 ☐ Environmental hazards
 ☐ Other: ________________________

4. Basic (Root) Causes


A. Personal Factors:

 ☐ Lack of knowledge or skill


 ☐ Physical or mental stress
 ☐ Fatigue or illness
 ☐ Improper motivation or attitude
 ☐ Inadequate training

B. Job System Factors:

 ☐ Inadequate supervision or leadership


 ☐ Poor engineering/design
 ☐ Lack of or unclear procedures
 ☐ Inadequate maintenance
 ☐ Inadequate tools or equipment
 ☐ Inadequate communication

5. Contributing Factors
List any additional factors that may have influenced the incident.

6. Corrective and Preventive Actions


Action Responsible Due Date Completed Verified By
Description Person (Y/N)

7. Follow-Up
Was the root cause addressed? ☐ Yes ☐ No

Has the corrective action been verified? ☐ Yes ☐ No

Date of follow-up review: __________

Follow-up conducted by: ____________


8. Sign-Off
Name Position Signature Date

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