Sample_Incident_Investigation_Form

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					TRUCKING SAFETY
COUNCIL OF BC                                  www.safetydriven.ca



                                       {Company Name Here}
                                    Incident Investigation Report
                Operation                           Date of Incident                     Time of Incident



   Conditions at time
     of occurrence

                Type of Incident                                           Recordable Injury

   □   Injury           □   Property damage     □     First aid        □   Medical aid         □   Restricted Work
   □   Near miss        □   Mobile              □     Lost time        □   Fatality            □   N/A
                            equipment
            Person(s) Involved                Department & Position                         Supervisor




   □ Employee          □ Contractor       □ Visitor     Time in Position (Month/Year)

   Age:                Sex: □ Male □ Female             Length of Service (Month/Year)

   Contractor Name

   Address of Incident



   Company Address &         (Complete if different)
   Phone Number

   Witness

   Witness

   Witness

          Date Reported (D/M/Y)             Date Investigated (D/M/Y)                Date of last SWP (D/M/Y)



   Cost Estimate (property/equipment damage, downtime):




           MODIFIED FROM TSCBC TEMPLATE ON NOVEMBER 12, 2012                                                     PAGE 1 OF 6
TRUCKING SAFETY
COUNCIL OF BC                                          www.safetydriven.ca



   Incident Description (List sequence of events leading to occurrence and immediate actions taken)

        Time                                                         Event




   Injury Information
   Nature of Injury

   □   Allergies / sensitivities               □   Cut / puncture / open wound       □       Hernia / Rupture
   □   Amputation                              □   Dislocation                       □       Infection
   □   Asphyxiation                            □   Electric shock                    □       Respiratory conditions
   □   Bruise / contusion                      □   Foreign body                      □       Scratch / abrasion
   □   Burn                                    □   Fracture                          □       Sprains / strains
   □   Concussion                              □   Hearing loss                      □       Other occupational injuries
                                                                                             _______________________


   Body Part

   □   Abdomen                □    L   □   R       □    Elbow        □   L   □   R       □    Knee            □    L   □     R
   □   Ankle                  □    L   □   R       □    Face         □   L   □   R       □    Leg             □    L   □     R
   □   Arm                    □    L   □   R       □    Foot         □   L   □   R       □    Mouth / teeth   □    L   □     R
   □   Back                   □    L   □   R       □    Hand         □   L   □   R       □    Neck            □    L   □     R
   □   Chest                  □    L   □   R       □    Groin        □   L   □   R       □    Shoulder        □    L   □     R
   □   Ear                    □    L   □   R       □    Head         □   L   □   R       □    Wrist           □    L   □     R
   □   Eye                    □    L   □   R       □    Hip          □   L   □   R       □    Multiple parts  □    L   □     R
                                                                                              __________________

   □   Other: ______________________               □                                     □




         MODIFIED FROM TSCBC TEMPLATE ON NOVEMBER 12, 2012                                                                 PAGE 2 OF 6
TRUCKING SAFETY
COUNCIL OF BC                                     www.safetydriven.ca


   Agent of Injury / Incident

       □    Chemicals                         □     Heat                                □      Office equipment
       □    Conveyor                          □     Hoisting equipment                  □      Pallets
       □    Debris / scrap                    □     Ladders                             □      Road conditions
       □    Electrical equipment              □     Load shifting                       □      Vehicle
       □    Fasteners                         □     Machine parts                       □      Weather conditions
       □    Fire / smoke                      □     Mobile equipment                    □      Work area
       □    Hand tools                        □     Noise                               □      Workplace violence
       □    Others:                           □                                         □


   Additional Injury Information:




   Cause Analysis
   Type of Event

   □   Mobile equipment accident          □   Contact with (electricity, heat,      □   Overstress, overpressure,
       (If vehicle road accident              cold, caustics, toxics, biological,       overexertion, ergonomic
       complete separate incident             noise)
       report for motor vehicle
       crashes)

   □   Struck against (running,           □   Caught in (pinch & nip points)        □   Environmental release / spill
       bumping into)
   □   Struck by (hit by moving object)   □   Caught between / under                □   Fire
                                              (crushed or amputated)

   □   Fall from elevation to lower       □   Fall from same level (slips &         □   Other: ___________________
       level                                  fall, trip over)




           MODIFIED FROM TSCBC TEMPLATE ON NOVEMBER 12, 2012                                                        PAGE 3 OF 6
TRUCKING SAFETY
COUNCIL OF BC                                      www.safetydriven.ca




   Immediate Causes

   □   Inadequate grip or hold                □   Failing to use PPE properly       □     Poor housekeeping / disorder
   □   Improper use of equipment / tools      □   Inadequate awareness of           □     Worksite conditions / congestion /
                                                  surroundings                            visibility

   □   Failure to follow safe work            □   Improper placement, storage or    □     Inadequate / improper protective
       practices or rules                         load securement                         equipment

   □   Improper lifting / pushing / pulling   □   Inadequate use of safety          □     Under influence of alcohol
                                                  devices                                 and/or drugs

   □   Failure to obtain assistance           □   Repetitive motion                 □     Inadequate labeling
   □   Failure to warn or instruct            □   Inadequate warning systems        □     Absence of guards and/or barriers
   □   Failure to lockout                     □   Weather conditions                □     Equipment failure
   □   Fire / Explosion                       □   Road conditions                   □     Vehicle failure
   □   Others:                                □                                     □
   Description of Immediate Causes




                      Recommended Corrective Actions                            By Whom     By When       Date Completed




         MODIFIED FROM TSCBC TEMPLATE ON NOVEMBER 12, 2012                                                               PAGE 4 OF 6
TRUCKING SAFETY
COUNCIL OF BC                                  www.safetydriven.ca



   Root Cause

   □   Inadequate work planning or        □   Inadequate assessment of            □     Inadequate change management
       Programming                            needs risks and / or hazards

   □   Inadequate communication           □   Inadequate maintenance              □     Inadequate purchasing
       standards                              system                                    standards: tools / equipment /
                                                                                        materials

   □   Inadequate policy, procedures,     □   Inadequate engineering and / or     □     Fatigue
       practices or guidelines                design
   □   Improper performance is rewarded   □   Inadequate or lack of inspections   □     Mental / physical stress
       (tolerated)
   □   Inadequate performance feedback    □   Inadequate employee skill           □     Inadequate physical capability
   □   Inadequate Supervision /           □   Inadequate training standards       □     Other - please specify:
       leadership                                                                       __________________________
   Description of Root Causes




                    Recommended Preventive Actions                            By Whom     By When       Date Completed




   Reasons for not taking Corrective / Preventative Action:




         MODIFIED FROM TSCBC TEMPLATE ON NOVEMBER 12, 2012                                                               PAGE 5 OF 6
TRUCKING SAFETY
COUNCIL OF BC                                www.safetydriven.ca




   Review and Approvals
                                                                           Phone     Date
                                     Print Name               Signature
                                                                          Number   (D/M/Y)

   Investigation Leader

   Investigation Team
   Member

   Safety Representative

   Immediate Supervisor

   Approved by Manager




   PLEASE ATTACH ADDITIONAL PAGES IF YOU REQUIRE MORE ROOM




         MODIFIED FROM TSCBC TEMPLATE ON NOVEMBER 12, 2012                             PAGE 6 OF 6

				
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Description: trucker safety