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Incident Report for Safety Teams

1) The incident investigation report provides details of a fatal incident including the injured person's name and department, nature of injury, location and date/time of incident. 2) A why tree analysis was conducted to identify key physical, human, and system factors. Deficiencies were noted across various safety systems. 3) Recommendations were provided along with responsibilities and target dates for implementation. The investigation was then reviewed and approved by management.

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Sri Kanth
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114 views8 pages

Incident Report for Safety Teams

1) The incident investigation report provides details of a fatal incident including the injured person's name and department, nature of injury, location and date/time of incident. 2) A why tree analysis was conducted to identify key physical, human, and system factors. Deficiencies were noted across various safety systems. 3) Recommendations were provided along with responsibilities and target dates for implementation. The investigation was then reviewed and approved by management.

Uploaded by

Sri Kanth
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

Incident Investigation Report

Incident Title:

Classification FATAL LTI MTC RWC FAC NMC PDFE


Mino HIPO Mino Major
Numbers
Details of Injured Company Employees Contractor Employees Third Party
Numbers

Name of Injured Age / Sex


Person:
Ticket no. / ofInjPerson:
Company /
Department: Contractor:
Nature of Injury :
Incident Reported by :

Any incident reported earlier in similar situation:

Location of Incident:
Incident Number:

Date of Incident: Time of Incident:


Incident Investigation Incident Investigation
Initiated: (Date / Time) Report Submission:
List of Records List of Persons
Reviewed during interacted during
Incident Investigation: incident investigation
process:
Brief Summary of Incident: It should be captured before to incidents.
Detailed Description of Incident :
Chronology of Events:

.
List of Facts collected during Investigation:

WHY Tree Analysis:


Please attach as an Annexure to the Incident Investigation Report

Incident Investigation – Why Tree


Date:

Time:

Physical
[System Factor]
Factor

Human
Factor

Key Factors Identified:

PHYSICAL FACTORS:
HUMAN FACTORS:

SYSTEM FACTORS
Systems that needs to be Reinforced:
Sr No. System Deficiency (Yes/No)
1. Emergency preparedness & contingency planning
2. Management of change personnel
3. Contractor safety management
4. Quality Assurance
5. Pre Start up safety review
6. Mechanical Integrity
7. Management of change Facility
8. Process Safety Information
9. Management of change Technology
10. Risk Assessment & Process Hazard Analysis.
11. Incident investigation
12. Observation & Audit
13. Motivational & Awareness
14. Effective Communication
15. Training & Development
16. Procedure & performance standard
17. Safety Personnel
18. Goal, Objective & Planning
19. Line Management accountability& Responsibility
20. Integrated Organization structure
21. Polices & Principle
22. Management commitment
23. Leadership in Safety
Recommendations:

Target Implementation
Sr No. Recommendation Responsibility
Date to be Verified by

3
4

Incident Investigation Completion:

Prepared by( Team Leader) :

Reviewed & Approved by :

Investigation Team :
.
1. Investigation Team Leader:
2. Investigation Team members:
3. Investigation Team members:
4. Investigation Team members:
5. Investigation Team members:

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