INCIDENT INVESTIGATION REPORT
Incident Report Nos       

Date of Incident       

Incident Classification       

Date of Investigation       

Investigation Team Member (Name & Designation)
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6.

List and attached documented information evidences eg photos at incident location, personnel / equipment involved, incident consequences; procedures, risk assessment, toolbox briefing, involved personnel and witness statements etc.
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applicant
INCIDENT INVESTIGATION REPORT
Immediate Causes – Unsafe Acts
NA 

Failure to follow policy & procedures 

Acts of violence 

Failure to use tools / equipment correctly 

Horseplay 

Failure to use personal protective equipment 

Improper loading 

Failure to identify hazard / risk 

Improper mechanical lifting 

Failure to communicate / coordinate 

Improper placement 

Failure to warn others 

Improper position for task 

Failure to secure 

Improper manual handling 

Failure to check / monitor 

Making safety devices inoperative 

Failure to react / correct 

Servicing equipment while in operation 

Operating at improper speed 

Using defective equipment 

Operating equipment without authority 

Under influence of alcohol / drugs 

Others – To specify 

Immediate Causes – Unsafe Conditions
NA 

Congested or restricted areas 

Inadequate or excessive illumination 

Defective tools / equipment 

Inadequate ventilation 

Fire / explosion hazard 

Inadequate warning system 

Noise exposures 

Inadequate communication 

Radiation exposures 

Inadequate information / data 

Temperature extremes 

Inadequate instruction / procedure 

Vibration exposure 

Inadequate preparation / planning 

Road conditions 

Inadequate support / assistance 

Poor housekeeping 

Inadequate guards / barriers 

Weather conditions 

Inadequate / no personal protective equipment 

Inadequate training 

Inadequate / no access / egress 

Others – To specify 

  

NA 

Explanation of Immediate Causes Identified

  
applicant
INCIDENT INVESTIGATION REPORT
Root Causes – Job Factors
NA 

Management / Leadership
Conflicting roles / responsibilities 

Inadequate management of change system 

Giving objectives, goals or standard that conflict 

Inadequate leadership on policy, procedure 

Inadequate incident reporting / investigation 

Inadequate / incorrect performance feedback 

Inadequate correction of prior hazard / incident 

Inadequate / lack of safety meetings 

Lack of supervisory / management job knowledge 

Inadequate identification of hazards 

Inadequate performance measurement & assessment 

Inadequate matching of individual competency 

Engineering
Inadequate technical design 

Inadequate ergonomic design 

Inadequate monitoring of initial operation 

Inadequate standards, specification, design criteria 

Inadequate monitoring of construction 

Inadequate evaluation of changes 

Inadequate assessment of potential failure 

Inadequate assessment of operational readiness

Training / Knowledge Transfer
Inadequate knowledge transfer 

Inadequate training effort 

Inadequate recall of training material 

No training provided 

Communications
Inadequate communication between organisation, groups and individuals 

Inadequate / no communication methods 

Work Planning
Inadequate work planning 

Excessive wear and tear 

Inadequate job placement 

Inadequate preventive maintenance 

Inadequate reference materials or publication 

Inadequate repair 

Inadequate inspection / monitoring 

Contractor Selection / Purchasing
Inadequate contractor selection 

Improper material storage 

Inadequate research on materials / equipment 

Inadequate specification 

Improper material transporting 

Inadequate mode of route or shipment 

Improper handling of material 

Inadequate identification of hazardous material 

Inadequate material packaging 

Improper salvage / waste disposal 

Inadequate receiving inspection and acceptance 

Tool and Equipment
Inadequate assessment of needs and risks 

Inadequate standards / specifications 

Inadequate adjustment / repair / maintenance 

Inadequate ergonomics considerations 

Inadequate availability 

Inadequate / no equipment record history 

Policies / Procedures / Standards
Inadequate communication of standards 

Inadequate maintenance of standards 

Inadequate development of standards 

Inadequate monitoring of compliance 

Others – To specify 

 

applicant
INCIDENT INVESTIGATION REPORT
Root Causes – Personal Factors
NA 

Skill / Knowledge Level
Inadequate initial training 

Misunderstood directions 

Infrequent performance 

Inadequate orientation 

Lack of Skill 

Lack of coaching 

Inadequate update training 

Inadequate initial instruction 

Lack of experience 

Inadequate review instruction 

Mental Stress
Meaningless or degrading activities 

Emotional overload 

Fatigue due to mental task load or speed 

Conflicting demands / directions

Extreme concentration / perception demands 

Frustration 

Confusing demands / direction 

Extreme judgement / decision demands 

Preoccupation with problems 

Behaviour
Excessive frustration 

Improper performance is rewarded / tolerated 

Inadequate reinforcement of proper behaviour 

Improper attempt to avoid discomfort 

Improper production incentives 

Inappropriate aggression 

Improper attempt to gain attention 

Improper supervisory example 

Inappropriate peer pressure 

Improper attempt to save time or effort 

Inadequate discipline 

Lack of incentives 

Proper performance is punished 

Inadequate performance feedback 

Mental State
Poor judgement 

Fears or phobias 

Slow reaction time 

Memory failure 

Low mechanical aptitude 

Inability to comprehend 

Poor coordination 

Low learning aptitude 

Emotional disturbance 

Influenced by medication 

Physical Capacity
Vision deficiency 

Other permanent physical disabilities 

Substance sensitivities or allergies 

Hearing deficiency 

Temporary disabilities 

Inadequate size or strength 

Other sensory deficiency 

Inability to sustain body positions 

Diminished capacity due to medication 

Reduced respiratory capacity 

Restricted range of body movement 

Physical Condition
Previous injury or illness 

Diminished performance  

Impairment due to drug or alcohol.

Fatique 

Blood sugar insufficiency 

Others – To specify 

 

NA 

Explanation of Root Causes Identified   

applicant
Incident Investigation Prepared by
Name

subcon
Signature    

Designation   

Supervisor