Incident Investigation Report
Injury / Illness / Property Damage/Fire / Near Miss
Complete within 24 hours and submit to Leslie Scheer and your HSE manager.
Personal
/ 1. Case No. (To be obtained by Leslie Scheer) / 2. Social Security No.Background Information
3. Employee Name / 4a. Age / 4b. Date of Birth / 5. Sex / 6. Regular OccupationM F / BOILERMAKERCARPENTERCONCRETE FINISHERELECTRICANEQUIPMENT OPERATORINSULATORIRONWORKERLABORERMANAGERMECHANICMILLWRIGHTPAINTERPIPEFITTERPROJECT ENGINEEROTHER
7a. Home Address / 7b. Phone Number(s)
8a. Date of Hire / 8b. Hourly Rate / 8c. Hours worked per day / 8d. Days worked per week / 8e. Days scheduled off
8f. Immediate Supervisors name/number / 8g. Who incident was reported to
9. Shift / 10. Location Name and Job Number / 11. Location Address
12a. Date of Incident / 12b. Time of Incident (24-hr clock) / 13. Time Shift Started/Ended / 14a. Date Reported / 14b. Time Reported
Yr. Mo. Day / Yr. Mo. Day
15a. Date Lost Time Began / 16a. Date Restricted Activity Began / 17. Date Returned to Full Duty
Yr. Mo. Day / Yr. Mo. Day / Yr. Mo. Day
18. Nature of Injury (choose all that apply) / 19. Injured Body Part (choose all that apply) / 20. Body Side Indicator
21 Occupational Skin Disease or Disorder22 Dust Disease of Lungs23 Respiratory Condition-Toxic Agents24 Poisoning-Toxic Material25 Disorder-Physical Agents26 Disorder-Repeated Trauma27 Hearing Loss29 Other Illness30 Emotional Reaction37. Eye - Foreign Body/Scratch40 PTS (Post Traumatic Stress)52 Dental Damage (formerly Teeth)55 Hernia68 Abcess70 Burn71 Back - Pre-existing Condition72 Knee - Pre-existing Condition 73 Shoulder - Pre-existing Condition74 Neck - Pre-existing Condition 80 Fracture - Simple81 Fracture - Compound83 Dislocation84 Strain or Sprain86 Puncture87 Laceration/Cut88 Amputation89 Foreign Body Under Skin90 Bite/Sting91 Abrasion/Scratch92 Contusion/Bruise93 Foreign Body94 Burn95 Electrical Shock96 Headache/Dizziness/Nausea from Exposure97 Avulsion98 Respiratory Irritation/Distress99 Heat Stress / 10 Head11 Face12 Eye13 Nose14 Chin15 Ear16 Teeth and Gums17 Jaw/Mouth18 Neck19 Throat20 Scalp31 Shoulder32 Upper Arm33 Elbow34 Lower Arm35 Wrist36 Hand37 Thumb38 Finger39 Palm 41 Index Finger42 Middle Finger43 Ring Finger44 Little Finger50 Trunk51 Abdomen53 Upper Back54 Lower Back55 Buttocks56 Chest57 Groin58 Ribs59 Lung60 Heart69 Pelvis 70 Toe71 Hip72 Thigh73 Knee74 Lower Leg75 Ankle76 Foot77 Instep78 Heel81 Great Toe82 Second Toe83 Third Toe84 Fourth Toe85 Fifth Toe90 Whole Body / L R Both
21. Name and Address of Physician/LHCP / 22. Name and Address of Hospital
23. Case Type / 24. If Fatality, Date of Death
1. F. A. Only2. Medical Treatment/Recordable3. Work Restricted/Recordable4. Lost Time/Recordable5. Injury-Free6. OSHA7. MSHA8. Non Occupational9. Fatality - Occupational10. Fatality - Non Occupational / Yr. Mo. Day
Incident
Description
/ 25a. Bldg. No. / 25b. Dept. No. / 25.c Exact Location of Incident (Equipment #) / 26. Onsite orOffsite
27. Occupation at Time of Incident / 28. Time in Occupation / 29. Mechanism of Injury
BOILERMAKERCARPENTERCONCRETE FINISHERELECTRICANEQUIPMENT OPERATORINSULATORIRONWORKERLABORERMANAGERMECHANICMILLWRIGHTPAINTERPIPEFITTERPROJECT ENGINEEROTHER / Yrs. Mos. / 1. Struck By2. Struck Against3. Contacted By4. Contact With5. Trapped In6. Caught On7. Caught Between8. Same Level Fall9. Different Level Fall10. Strain/Overexertion11. Expsoure
30.Job Being Performed at Time of Incident
31. What Occurred?
32. Type of Incident (check all that apply)
Injury/Illness
Potential Exposure
Near Miss
Other: / Spill
Fire
Excavation
Environmental / Lock and Tag
Electrical
Ergonomics
Equipment/Vehicle Operator / Property Damage:
Est. Cost$
Motor Vehicle Accident:
Est. Cost$
33. List of Equipment/Property Involved in Incident (include if applicable manufacturer type and equipment No.)
Equipment/Property is Owned Leased Client-Owned
Estimated Cost of Repair: $
34. List permits/work authorizations in place for tasks at time of incident:
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Incident Investigation Report
Contributing Actions (items 39-40, five entries max. per item) / Contributing Conditions
35.What actions caused or contributed to the incident?
(give details on additional page as required) / 36.What condition of tools, equipment, or job site caused or contributed to the incident? (give details on reverse side as required)
a.Operating without necessary training
b.Failure to make secure
c.Operating at unsafe speed
d.Inadequate warning/signal
e.Nullified safety device
f.Used defective equipment
g.Used equipment unsafely
h.Used wrong tool/equipment
i.Equipment not at zero energy state / j.Riding hazardous equipment
k.Improper position/posture
l.Influenced by distraction
m.Inadequate protective equipment
n.Standard proceduredeviation
o.Other contributing action
p.No contributing action determined / a.Inadequate guard/safety device
b.Hazardous attire
c.Inadequate warning system
d.Fire or explosion hazard
e.Unsecured against movement
f.Poor housekeeping
g.Protruding object hazard / h.Close clearance/congestion
i.Hazardous arrangement/storage
j.Defective tools/equipment
k. Atmospheric condition
l.Illumination/noise hazard
m.Other unsafe condition
n. No unsafe condition
37.What caused or influenced above contributing actions? / 38.What caused or influenced above contributing conditions?
a.Unaware of job hazards
b.Inattention to hazard
c.Unaware of safe method
d.Low level job skill
e.Tried to gain or save time
f.Tried to avoid extra effort
g.Tried to avoid discomfort / h. Influence of emotions
i. Influence of fatigue
j. Influence of intoxicant/drugs
k. Defective vision/hearing
l. Influence of illness
m. Other factors
n. Unknown factors / a. Caused by employee
b. Caused by another employee
c. Defective from normal use
d. Defective via abuse/misuse
e. Inadequate safety inspection
f. Inadequate housekeeping/cleanup
g. Faulty design/construction / h. Other contractor
i. Inadequate preventative maintenance
j. Purchasing process
k. Deteriorating exposure
l. Management acceptance
m. Other source cause
n. Unknown source cause
39. Incident Analysis – Root Cause (check only one)
Equipment/Material Problem
1a.Defective or failed part
1b. Defective or failed material
1c.Defective weld, braze, or soldered joint
1d.Manufacturer shipping or marking error
1e.Electrical or instrument noise
1f.Contaminant
1g.End of life failure (equipment or material)
Procedure Problem
2a. Defective or inadequate procedure
2b.Lack of procedure / Personnel Error
3a.Inadequate work environment
3b.Inattention to detail
3c.Procedure not used or used incorrectly
3d.Communication problem
3e.Other human error
Design Problem
4a.Inadequate person/machine interface
4b.Inadequate or defective design
4c.Error in equipment or material selection
4d.Drawing, specification, or data error / Training Deficiency
5a.No training provided
5b.Insufficient practice or hands on experience
5c.Inadequate content
5d.Insufficient refresher training
5e.Inadequate presentation or materials
Management Problem
6a.Inadequate administrative control
6b.Work organization/planning deficiency
6c.Inadequate supervision
6d.Improper resource allocation
6e.Policy not adequately defined, disseminated, or enforced
6f.Other management problem / External Phenomenon
7a.Weather or ambient condition
7b.Power failure or transient
7c.External fire or explosion
7d.Theft, tampering, sabotage, or vandalism
8Other
40. HPI
Task Demands / Work Environment / Individual Capabilities / Human Nature
1a.Time pressure (in a hurry)
1b.High Workload (memoryrequirements)
1c.Simultaneous, multipletasks
1d.Repetitive actions, monotonous
1e.Irrecoverable acts
1f.Interpretation requirement
1g.Lack of or unclear standards / 2a.Distractions/Interruptions
2b.Changes/Departures from routine
2c.Confusing displays or controls
2d.Workarounds/OOS instruments
2e.Hidden system response
2f.Unexpectedequipmentconditions
2g.Lack of alternativeindication
2h.Personality conflicts / 3a.Unfamiliarityw/task/Firsttime
3b.Lack of knowledge (mental model)
3c.New technique not used before
3d.Imprecise communication habits
3e.Lack of proficiency/ Inexperience
3f.Indistinct problem solving skills
3g.“Hazardous” attitude for critical task
3h.Illness/Fatigue / 4a.Stress (limits attention)
4b.Habitpatterns
4c.Assumptions(inaccurate mental picture)
4d.Complacency/
Overconfidence
4e.Mindset (“tuned” to see)
4f.Inaccurate risk perception (Pollyanna)
4g.Mental shortcuts (biases)
4h.Limited short-term memory
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Incident Investigation Report
41. What action has been taken to prevent recurrence?
(give details on reverse side)
a.Use safer materials/supplies
b. Improve illumination
c.Improve ventilation
d.Mandatory prejob instructions
e.Job reassignment of employee
f.Improved inspection procedure
g.Improved cleanup procedure / h.Improved enforcement
i. Order STA done on job
j.Order STA revision
k.Install/revise safety guard/device
l.Require protective equipment
m.Repair/replace equipment
n.Improved storage/arrangement
o.Improve design/construction / p.Eliminate congestion
q.Reinstruction of employees involved
r.Warning to employees involved
s.Discipline of employees involved
t.Preventive instruction of others doing job
u.Correction other than above
Corrective Actions Required to Prevent Recurrence
42.Required Corrections: What corrective actions will be taken to prevent recurrence of the incident? See Section 45
/ Person Responsible / Target Date for Completiona.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
Note: Use additional pages if necessary—number additional pages (f) 46-2, (f) f6-3, etc., and attach.
43. Additional Pages Attached No Yes (check all that apply)
a. Photo Log
b. Employee Statement / c. Witness Statement (how many?)
d. Ergonomic Page / e.Environmental Page
f.Corrective Actions (continuation page)
44. Immediate Supervisor (name/title): / Date Completed / 45. Other Participants in Investigation
Yr.Mo. Day / No Yes (See list on page 2)
46. Report Prepared by (name/title): / 47.Reviewed by Management (name/title): / Yr. Mo. Day
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/ Form 000.653.F0198
Incident Investigation Report
(b.) Involved/Injured Employee’s Statement
Employer Name (print) / Employee Name (Print)
Home Address (street)
City/State/Zip/Country / Telephone No.
Age / Date of Birth / Sex / Date of Incident / Time of Incident / Marital Status
MarriedDivorcedSingleWidow/WidowerOther / No. of Children
Instructions: In your own words, describe the incident in as much detail as possible. Speak to who, what, where, when, why, and how. Use additional paper if necessary
How did the incident occur?
How could the injury/illness have been prevented?
BY SIGNATURE, THIS STATEMENT IS THE TRUTH TO THE BEST OF MY KNOWLEDGE.
SIGNATURE DATE
TO BE COMPLETED BY EMPLOYEEE IF HE/SHE DOES NOT SEEK MEDICAL TREATMENT.
I HAVE REPORTED A WORK RELATED INJURY/ILLNESS AS DESCRIBED ABOVE. AT THIS TIME, I DECLINE MEDICAL TREATMENT AS OFFERED BY MY EMPLOYER AND WISH TO BE ALLOWED TO RETURN BACK TO WORK AT MY NORMAL JOB DUTIES WITHOUT ANY RESTRICTIONS OR SPECIAL ACCOMODATIONS. AS I HAVE DECLINED MEDICAL TREATMENT, I UNDERSTAND THAT I MAY BE REQUIRED TO SUBMIT POST INCIDENT DRUG SCREEN AS A RESULT OF THE REPORTED INJURY.
Signature / Date
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/ Form 000.653.F0198
Incident Investigation Report
(c.) SUPERVISOR or WITNESS STATEMENT
Employer Name (print) / Employee Name (Print)
Home Address (street)
City/State/Zip/Country / Telephone No.
Age / Sex / Date of Incident / Time of Incident
Instructions: In your own words, describe the incident in as much detail as possible. Speak to who, what, where, when, why, and how.
USE ADDITIONAL PAPER IF NECESSARY
How did the incident occur?
How could the injury/illness have been prevented?
BY SIGNATURE, THIS STATEMENT IS THE TRUTH TO THE BEST OF MY KNOWLEDGE.
Signature / Date
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/ Form 000.653.F0198
Incident Investigation Report
(f.) MEDICAL AUTHORIZATION TO TREAT
Employee Name / Date of Incident
Employee Address (street/city/state/zip / Social Security No.
Authorized by (print name and title) / Phone No.
Injury / Illness Description (include all body parts affected)
PLEASE FORWARD ALL BILLS TO:
Plant Performance Services
Attn: Danny Trahan
777 Highway 397
Lake Charles, LA 70615 / 337.656.4647 / OFFICE
337.421.0050 / FAX
This authorizes medical treatment for the aforementioned employee of plant performance services. Please note that if thE condition is found to be non-occupational, all charges incurred AFTER THE INITIAL SERVICE DATE will become the responsibility of the employee, and the employee agrees to these terms by his/her signature below.
Employee Signature
/Date
AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATIONI HEREBY AUTHORIZE YOU (MEDICAL PROVIDER) TO DELIVER, DISCLOSE AND RELEASE ALL INFORMATION CONCERNING CARE RENDERED TO ME FOR THE REPORTED OCCUPATIONAL ILLNESS/INJURY IN REGARDS TO THE INCIDENT AS DESCRIBED ABOVE, INCLUDING BUT NOT LIMITED TO: ER VISITS, DIAGNOSIS, DIAGNOSTIC PROCEDURES (WITH INTERPRETATION), MEDICAL HISTORY, REPORTS OF MEDICAL EXAMS, PRE-OPERATIVE, OPERATIVE AND POST-OPERATIVE REPORTS TO MY EMPLOYER, PLANT PERFORMANCE SERVICES (P2S) AND IT’S REPRESENTATIVES.
A PHOTO STATIC COPY OF THIS AUTHORIZATION SHALL BE CONSIDERED AS EFFECTIVE AND VALID AS THE ORIGINAL.
Employee Signature / Date
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