Incident No by liaoqinmei



Safety Event                                          Incident No:
Investigation Report
This report is strictly private and confidential. The report has been circulated to those persons
identified in the distribution list and in accordance with the Specific Incident Service Order:
Safety Event Investigation SO/8/2/1 . Under no circumstance should this report be copied and
circulated further without the written permission of any person named within the report and
Health and Safety Manager

Category of                                                                Dangerous
                   Injury         Ill-Health         Near Miss
Incident:                                                                  Occurrence

Name of Injured Person

                                                    Time of
Date of Incident

Location of Incident

Nature of Injury / Ill Health

Summary: (Brief details – what, where, who and measures taken)

Investigation Level:                      Level 2                         Level 3

Appointed Incident Investigation Manager

Members of Investigation Team (Level 3 Only):
                   Name                                              Position

Part 1: Investigation Evidence Gathering

1. Where and when did the incident happen?

2. Who was injured/suffered ill health or was otherwise involved with the incident?

3. What injuries or ill health effects, if any, were caused?

4. How did the incident happen? (Note any equipment involved)

5. What activities were being carried out at the time?

6. Was there anything unusual or different about working conditions?

7. Were there adequate safe working procedures and were they followed?

8. Was the risk known? If so, why wasn’t it controlled?

9. Did the organisation and arrangements of the work influence the incident?

10. Was maintenance and cleaning sufficient? If not, why not?

11. Were the people involved competent and suitable?

12. Did the physical workplace influence the incident?
(Fixed structure/construction/ground conditions/ physical makeup etc)

13. Did the nature or shape of materials influence the incident?

14. Did difficulties using plant and equipment influence the incident?

15. Was the equipment provided for safety suitable and sufficient?

16. Did other conditions influence the incident?

Part 2: Analysis

 17. Analysis of the Basic Risk Factors.
 (What were the Immediate and Underlying Causes).
 1. Where satisfactory control measures are in place detail the control measures in the ‘Evidence’ column for the relevant BRF and attach/direct to
    this evidence.
 2. Do not include recommendations below only factual information for which you have evidence.
 3. WHY is in relation to what happened in the previous column.

                                                                                                        Route Cause
                                                     Brief resultant             Why this                Why that                 Why that
           BRF                  Evidence
                                                      safety event               happened                Happened                 Happened
 Ergonomically poorly
 designed equipment, that
 is user-unfriendly.
 Tools & Equipment
 Poor quality, condition,
 suitability of materials,
 tools, equipment and
 No or insufficient attention
 given to keeping the work
 area clean or tidy.
 No or inadequate
 performance of
 maintenance tasks and
 Error Enforcing
 Unsuitable physical
 conditions and other
 influences that have a
 disadvantageous effect on
 human functioning.

                                                                        Route Cause
                                           Brief resultant   Why this    Why that     Why that
          BRF                   Evidence
                                            safety event     happened    Happened     Happened
Insufficient quality or
availability of procedures,
guidelines, instructions
and manuals
(specification, paperwork,
use in practice).
No or insufficient
competence or
experience among
No or ineffective
communication between
the various sites,
departments or
employees or with trade
Incompatibility of
Safety verses productivity,
incentives, political, social
or individual goals.
Shortcomings in the
organizations structure,
philosophy, management
strategies resulting in
inadequate or effective
No or insufficient
protection (PPE) of
people, material and
environment against the
consequences of
operational disturbances.

Part 3: Conclusions

18. Why the incident occurred:

19. Immediate Causes:

20. Underlying Causes (Route Causes) :

21. Do similar risks exist elsewhere? If so, what and where?

22. Have similar incidents happened before? Give details including Incident No.

23. Signed on behalf of the investigation team

Name                                     Signature

Part 4: Risk Control Action Plan

 24. What additional risk control measures are required?
 Level 2: To be determined by a Health and Safety Department.
 Level 3: Investigation Team to discuss and agree.
 Health and Safety Department to discuss and agree Risk Control Action Plan with relevant Managers(s) and/or others as required.

  Additional Control Measure                       Target                 Person                      Date                Signed*
           Required                                 Date                Responsible                 Completed          (*see below)

 * The person nominated as being responsible for implementing control measures
 must sign to confirm work completed.

 25. Which risk assessments and safe working procedures need to be reviewed?

        Name of risk assessment                             Target                                                       Date
                                                                               Person Responsible
        safe working procedure                               Date                                                      Completed

26. Risk control action plan agreed by:
Level 2: Investigation Officer, Health & Safety Department and relevant Managers.
Level 3: Representative of Investigation Team, Health & Safety Manager and relevant Managers/Directors.

               Name                                     Position                                      Signature

To top