Short Description of Incident:
Supervisor of Area where incident occurred:
OH&S Representative for Area:
Statutory regulations for activity:
Documented work instruction for activity?
LOCATION SKETCH (show movement direction, distances, relative locations, etc.)
Who was involved in the incident?
Who was working with the involved person?
Who instructed and/or assigned the job to the person?
Who has information on events prior to the incident?
Who assessed the risks involved in the job?
Who was responsible for implementing risk controls?
Who checked statutory knowledge of involved person? (if applicable)
Who checked safety of equipment/plant prior to work commencing?
Where did the incident occur?
Where did the damage occur?
Where was the supervisor at the time?
Where were the witnesses at the time?
How did the incident occur? (list steps that led to incident)
How did the injury occur? (list steps that led to injury)
List possible contributing factors.
List all essential contributing factors.
How could the incident have been avoided? (Subject to Job Analysis)
How could the injury have been avoided?
How could better job design be achieved?
How could the supervisor have prevented the incident?
How could better equipment design help?
How can we detect systems failure before it occurs?
How can we control failure (minimise consequences)?
What could we do instead?
PREVENTATIVE/CORRECTIVE ACTION
