Incident/Accident Analysis Company name: Employee: Department: Supervisor: Date and time of incident: Date and time reported: Incident location: Witnesses: Describe incident completely: Identify system problems that contributed to the incident/accident: Management Management systems Employee systems Employee Consider: Consider: Policy enforcement Procedures followed Hazard recognition Shortcuts Accountability Appropriately Supervisor training trained Corrective action Experience with the Production priority task Proper resources Physically able to Job safety training do the work Hiring practices PPE used Maintenance Stressful conditions Adequate staffing System Safety attitude Safety observations factors Equipment Equipment systems Environment Environment systems factors Consider: Consider: System Proper tool layout selection hemicals used Tool availability Temperature Maintenance Visual warnings Radiation Guarding Weather Terrain Vibration Ergonomics Lighting Ventilation Housekeeping Biological Corrective actions/best practices: Who will implement? By when? Date done? Consider: Elimination/substitution Engineering controls Administrative controls Personal protective equipment (PPE) Person(s) conducting analysis: Date: Copy to: Safety committee, management, or president
Incident/Accident Analysis Company name: Employee: Department: Supervisor: Date and time of incident: Date and time reported: Incident location: Witnesses: Describe incident completely: Identify system problems that contributed to the incident/accident: System factors Management Consider: Policy enforcement Hazard recognition Accountability Supervisor training Corrective action Production priority Proper resources Job safety training Hiring practices Maintenance Adequate staffing Safety observations Management systems Employee systems Employee Consider: Procedures followed Shortcuts Appropriately trained Experience with the task Physically able to do the work PPE used Stressful conditions Safety attitude System factors Equipment Consider: Proper tool selection Tool availability Maintenance Visual warnings Guarding Equipment systems Environment systems Environment Consider: layout hemicals used Temperature Radiation Weather Terrain Vibration Ergonomics Lighting Ventilation Housekeeping Biological Consider: Elimination/substitution Engineering controls Administrative controls Personal protective equipment (PPE) Corrective actions/best practices: Who will implement? By when? Date done? Person(s) conducting analysis: Date: Copy to: Safety committee, management, or president