Incident Report Form

INCIDENT REPORT FORM

Date:
Page 1 of 14
Rev.:
 Incident Report Form

Part 1: Incident Description

☐ Preliminary ☐ Final

Incident Date: Location:

Company: Work area:

Name Company Time Phone

Notified by:

Notified to:

Incident description

Incident Classification

Work related
Non work Injury No injury
related
Time off No time off Mat. damage Env. damage No damage
Restricted
Asset
☐ Work Case ☐ Near Miss
☐ Fatality (FAT) Damage (AD) ☐
(RWC) (NM) (*)
Non Work
Medical Treat. Motor Vehicle Environmental
☐ Related ☐ ☐ ☐
Case (MTC) Inc. (MVI) Incident (EI)
(NWR)
Lost Time Security
☐ ☐
Incident (LTI) Breach (SB)
First Aid Case Fire Incident
☐ ☐
(FAC) (FI)

(*) To be assessed using Attachment 1

Site HSE Supervisor

Name:

Signature:

Date:
Page 2 of 14
Rev.:
 Final Incident Report Form

Part 2: Incident Investigation

2.1 Incident details

☐ Fatality (FAT) ☐ Lost Time Incident (LTI)

Full IP’s name: N/A
Time off

Date of birth: ID:

Company: Position:
Crew: Lost work days:
(if already known)
Injury

☐ Restricted Work Case (RWC) ☐ Medical Treatment Case (MTC) ☐ First Aid Case (FAC)
Full IP’s name: N/A
No time off

Date of birth: ID:

Company: Position:
Crew: Restricted work days:
(if applicable)
MTC / FAC
justification:

☐ Asset Damage (project) (AD) ☐ Asset damage (3rd party) (AD) ☐ Fire Incident (FI)
Asset: N/A ID:
Owner: Cost (€):
Asset description:
Damage description:
Cause of damage:
With damage

☐ Motor Vehicle Incident (MVI)

Model: N/A License plate:
Owner: VIN number:
Damage description:
Driver’s full name:
No injury

Date of birth: ID:

Company: Position:
Cause of damage:
Passengers:

☐ Environmental Incident (EI)

Env.

Description: N/A
Quantity of emissions / spill (L):

☐ Near Miss (NM) ☐ Security Breach (SB) (Refer to Attachment 1 of this document to assess Near Miss)

Description: Hit by compressed air

No damage

Missing assets: N/A

Cost estimate (€): N/A
Consequences: ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1
Likelihood: ☐ 5 ☐ 4 ☐ 3 ☐ 2 ☐ 1
Potential risk score: ☐ Extreme ☐ High ☐ Medium ☒ Low

Date:
Page 3 of 14
Rev.:
 Final Incident Report Form

2.2 Outcome

Place mark on injury zone only in incidents resulting in injury

Head Torso Arms Legs Others

☐ Cheekbone ☐ Abdomen ☐ Arm ☐ Ankle ☐Internal inj.
☐ Chin ☐ Back ☐ Elbow ☐ Foot ☐ Several parts
☐ Ear ☐ Buttocks ☐ Hand ☐ Knee ☐Skin
☐ Eyebrow ☐ Chest ☐ Wrist ☐ Leg
☐ Forehead ☐ Hip
☐ Lips ☐ Neck
☐ Nose ☐ Shoulders
☐ Skull

Date:
Page 4 of 14
Rev.:
 Final Incident Report Form

2.3 People, Environment, Equipment, Procedures, Organization (PEEPO)

PEEPO (People, Environment, Equipment, Procedures, Organization) is a tool used for organizing facts
and ideas that help establishing a timeline of events sequence and a root cause tree, divided in five
categories, for subsequent analysis. Acts, Conditions or deficiencies found in this initial collection of
data are to be examined for their potential as contributing factors to the incident.

Please refer to Incident Report Guidelines, Section 2.3 for more detailed instructions.

Factors Facts and ideas

 Length of employment
 Roster
 Training & competency, PPEs  The laborer holding the nozzle failed to close the valve of
 Experience the nozzle.
People  Understanding of task  Miscommunication between the laborers.
 Fatigue  Complacency of the laborer.
 Personal Issues / Stress
 Alcohol / drugs, Communication

 Weather
 Housekeeping
 Location / design of work area
Environment  Visibility
 Access / egress
 Ground and noise conditions

 Fault or failure
 Design / quality
 Availability
Equipment  Modifications  The handle of lever valve was damaged.
 Maintenance
 Inspections / pre-starts
 Risk assessment on equipment
 Procedure / Safe Work Instruction
 Up to date
 Identification of hazards
 Adequate permit  Inspection of the lever valve was not done prior to start
Procedures  Inspections the activity.
 Last Minute Risk Assessments, JSA
 Registers
 Management of change
 Supervision
 Provided training
 Corrected Hazards
 Safety systems  Poor work planning.
Organization  SAOs  Lack of Supervision.
 Available safety equipment
 Inspections and maintenance
 Similar incidents

Date:
Page 5 of 14
Rev.:
 Final Incident Report Form

2.4ILCI Loss Causation Model

Lack of Basic Immediate

Incident Loss
control causes causes

FAILED TO HANDLE OF
POOR WORK WORKER HIT BY N/A
CONDUCT LEVER VALVE
PLANNING COMPRESSED AIR With the
Creates INSPECTION Leadingto WAS DAMAGED Causing
resulting

The International Loss Control Institute (ILCI) Loss Causation Model represents the sequence of events that allow an actual loss to occur. It
can be used to understand the various causes leading to incidents and provides a framework for the subsequent incident investigation.

This model takes a proactive approach to loss prevention and suggests that incidents are symptoms of lack of control in the management
system, which is to be identified. The various events are explained by working backwards from the loss. Please refer to Attachment 2: ILCI
Loss Causation Model for the events checklist and refer to Incident Report Guidelines, Section 2.4 for more detailed instructions.

This model can be replaced by other commercial root cause analysis methods such as TapRooT, SCAT, TRIPOD or similar.

Date:
Page 6 of 14
Rev.:
 Final Incident Report Form

2.5Events timeline(can be replaced with any commercial events timeline)

Event Time Description

Event 1

Event 2

Event 3

Event 4

Event 5

Event 6

Event 7

Event 8

Date:
Page 7 of 14
Rev.:
 Final Incident Report Form

2.6 Immediate actions

Action Description

Action 1

Action 2

Action 3

Action 4

Action 5

Action 6

Action 7

Date:
Page 8 of 14
Rev.:
 Final Incident Report Form

2.7 Preventive / corrective actions follow-up and status

Type Closing
Action Description Responsible Due date
(Prev/corr) date
Refresher training on safe operation with portable air compressor &
A1 Corrective Edgardo 02/05/19 02/05/19
proper use of PPE shall be conducted to the asphalting cleaning crew
Authorized person shall conduct pre-operational inspection of the
A2 Corrective Edgardo 02/05/19 02/05/19
equipment prior to use.
Supervisor/foreman shall ensure that workers are aware regarding
A3 Corrective the job sequence and procedures including the hazards involved and Edgardo 02/05/19 02/05/19
the precautions to perform the activity safely.
Competent/skilled workers shall be assigned to conduct air cleaning
A4 Corrective Edgardo 02/05/19 02/05/19
activity
The incident shall be cascaded to all in the mass toolbox meeting to
A5 Preventive Edgardo 05/05/19 05/05/19
prevent recurrence.
Safety alert shall be developed and to be communicated throughout
A6 Preventive Edgardo 05/05/19 05/05/19
the project.

A7

Date:
Page 9 of 14
Rev.:
 Final Incident Report Form
HIT BY COMPRESSED AIR

2.8 Investigation team

Name ID Company Position

2.9 Additional comments

N/A

2.10 Attachments (e.g. photographic evidence)

(Enumerate here and attach separately).

INCIDENT TOOLBOX MEETING

Date:
Page 10 of 14
Rev.:
 Final Incident Report Form
HIT BY COMPRESSED AIR

Name Position Date Signature

Reported by:

Reviewed by:

Approved by:

Date:
Page 11 of 14
Rev.:
 Final Incident Report Form
HIT BY COMPRESSED AIR

Attachment 1: Near Miss Risk Assessment

Consequence Matrix
5 4 3 2 1
Catastrophic Major Moderate Minor Slight/none
Multiple fatalities / Restricted work case /
Lost time incident /
Injury permanent total Single fatality medical treatment First aid case
partial disability
disability case
Loss > 5,000 €, fire
Loss > 500 €, flames, Minor loss,
emergency services, Loss > 50 €, sparks,
Mat. damage Loss > 50,000 € displacement of overheat,
disruption in operations, minor bumps
personnel, bumps noncollisions
crashes
Non-complying
Radioactive spill, Affection to protected
Env. Contaminated spill emissions Minor spill
uncontrolled spill area
(noise/dust/odor)

Likelihood Matrix
5 Almost certain
4 Quite likely
3 Possible
2 Unlikely
1 Remote
Expected to occur frequently (more than once a year)
Expected to occur occasionally (once every year)
Expected to occur under unusual circumstances (once every three years)
Could occur at some time (once every 10 years)
May occur only in exceptional circumstances (unheard of in the industry)

Risk Assessment Matrix

Consequences
5 4 3 2 1
Catastrophic Major Moderate Minor Slight/non
Almost
5 E E E H H
certain
Quite
4 E E H H M
possible

3 Possible E E H M L
2 Unlikely E H M L L
1 Remote H H M L L

Potential Risk Score

Code Risk level Required actions
Immediate priority corrective measures and re-assessment. Risk reduction plan
E Extreme
must be developed and approved by management.
High priority corrective measures. Review and introduce additional controls to
H High
reduce risk.
Confirm presence of reasonable safeguards and management systems. Monitor
M Medium
and maintain.
L Low Monitor and manage risk accordingly.

Date:
Page 12 of 14
Rev.:
 Final Incident Report Form
HIT BY COMPRESSED AIR
Attachment 2: ILCI Loss Causation Model
Lack of control
☐ 1. Leadership and administration
☐ 2. Management training
☐ 3. Planned inspections
☐ 4. Job task analysis and procedures
☐ 5. Job and task observations
☐ 6. Emergency preparedness
☐ 7. Organizational rules
☐ 8. Accident and incident investigations
☐ 9. Accident and incident analysis
☐ 10. PPE
Basic causes
Personal factors
☐ 1. Inadequate capability / behavioral
☐ 2. Lack of knowledge
☐ 3. Lack of skill
☐ 4. Stress
☐ 5. Fatigue
☐ 6. Improper ventilation
Immediate causes
Acts
☐ 1. Violation (intentional)
☐ 2. Violation (unintentional)
☐ 3. Improper position (in the line of fire)
☐ 4. Overexertion or improper posture
☐ 5. Work or motion at improper speed
☐ 6. Improper lifting or loading
☐ 7. Improper use/position of
tools/equipment/materials/products
☐ 8. Servicing of energized equipment / inadequate
energy isolation
☐9. Failure to warn of hazard
☐ 10. Inadequate use of safety systems
☐ 11. PPE not used or used improperly
☐ 12. Equipment or materials not secured
☐ 11. Health control and services
☐ 12. Program evaluation systems
☐ 13. Purchasing and engineering systems
☐ 14. Personal communications
☐ 15. Group meetings
☐ 16. General promotion
☐ 17. Hiring and placement
☐ 18. Records and reports
☐ 19. Off-the-job safety
Job factors
☐1. Inadequate leadership supervision
☐ 2. Inadequate engineering
☐ 3. Inadequate purchasing
☐ 4. Inadequate maintenance
☐ 5. Inadequate tools / equipment
☐ 6. Inadequate work standards
☐ 7. Wear and tear
☐ 8. Abuse or misuse
Conditions
☐ 1. Inadequate/defective guards or protective
barriers
☐ 2. Inadequate/defective PPE
☐ 3. Inadequate/defective warning systems/safety
devices
☐ 4. Inadequate security provisions or systems
☐ 5. Inadequate design/specification/management
of change
☐ 6. Inadequate/defective
tools/equipment/material/products
☐ 7. Inadequate maintenance/inspection/testing
☐ 8. Congestion, clutter or restricted motion
☐ 9. Inadequate surfaces, floors, walkways or roads
☐ 10. Hazardous atmosphere
(explosive/toxic/asphyxiating)
☐ 11. Storms or acts of nature
☐ 12. Inadequate training/competence
Date:
Page 13 of 14
Rev.:
 Final Incident Report Form
HIT BY COMPRESSED AIR

☐ 13. Disabled or removed guards, warning systems or

☐ 13. Inadequate work standards/procedures
safety devices
☐ 14. Inadequate hazard identification or risk
☐ 14. Improper decision making or lack of judgement
assessment
☐ 15. Lack of attention/distracted by other
☐15. Inadequate communication
concerns/stress
☐ 16. Acts of violence ☐ 16. Inadequate supervision
☐ 17. Use of drugs or alcohol ☐ 17. Poor leadership/organisational culture
☐ 18. Fatigue ☐ 18. Failure to report/learn from events

Incident
Type of contact Contact with
☐ 1. Struck against ☐ 1. Electricity
☐ 2. Struck by ☐ 2. Heat
☐ 3. Caught in ☐ 3. Cold
☐ 4. Caught on ☐ 4. Radiation
☐ 5. Caught between ☐ 5. Caustics
☐ 6. Slip ☐ 6. Noise
☐ 7. Fall on same level ☐ 7. Toxic or noxious substances
☐ 8. Fall to below ☐ 8. Machinery
☐ 9. Overexertion

Loss
☐ 1. People ☐ 4. Material
☐ 2. Property ☐ 5. Quality
☐ 3. Environmental ☐ 6. Safety

Date:
Page 14 of 14
Rev.: