• Incident Reporting & Investigation

  •  INCIDENT NOTIFICATION - Part 1

    The reporting worker must fill out and complete the Incident Notification which is submitted to the Site Supervisor & a copy to the reporting worker. The Site Supervisor will review the information provided to determine if further investigation is required. 

    INCIDENT INVESTIGATION - Part 2

    The investigation is to be completed by the Site Supervisor and/or designee in cooperation with any additional persons (i.e. H&S Dept, H&S Committee, affected worker, etc.) to update and/or confirm initially reported information and close out or assign additional corrective action to prevent future loss. 

    SUPERINTENDENT INCIDENT REVIEW - Part 3

    The completed investigation is sent to the responsible Superintendent for review, comments, corrective actions and sign-off. 

    MANAGER INCIDENT REVIEW - Part 4

    The completed investigation is sent to the responsible Manager for review, comments, corrective actions and sign-off. 

     *Please remember to take photos of the scene, equipment, damage, etc., and gather statements from affected workers whenever it is reasonably practicable to do so*

  • Part 1 - Incident Report

  • Incident Reporting Instructions

    1. Incidents can be reported by any person at the work site.
    2. Complete as much information as you can, as soon as possible, after the incident occurs.
  • Date/Time of Incident:*
     - -
  • Work Site*

  • Incident Types

    (READ BEFORE SELECTING INCIDENT TYPE)

    Near Miss / Hazard ID: Any incident that could have potentially been an injury or damage. A lucky escape or close call. THIS SELECTION CANNOT BE COMBINED WITH OTHER INCIDENT TYPES.

    Injury/illness: Incidents where a person is hurt, or becomes sick that may be related to work acitivties.

    Property Damage/Operational Loss: When equipment and/or property is damaged, stolen or goes missing.

    Unsafe Work Refusal: If a worker refuses to work due to an unsafe condition.

    Utility Strike: When utlity services are hit or damaged.

    Vehicle Incident (VI): All types of vehicle incident company and/or other involved vehicles.

    Violence and/or Harassment: When a worker feels threatened, and/or exposed to violent behaviour. 

     

  • Incident Type(s):*
  • Did the Incident Occur?*
  • Weather Conditions (select all that apply):
  • Did Anyone Witness the Incident?*
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  • Was Anyone Else Directly Involved or Affected by this Incident (i.e. contractors, visitors, public, etc.)?*
  • Have External Authorities and/or Emergency Services Been Contacted/Involved?*
  • Scene Response Included:*

  • Injury/Illness Notification

  • What Side of the Body Has Been Affected?*
  • Was First Aid Provided at Site?*
  • Date First Aid was Provided?*
     - -
  • Was a First Aid Report Completed?*
  • Did the Affected Individual Seek Medical Aid from a Medical Practitioner (Doctor, Walk-in Clinic, Hospital)?*
  • Date Medical Aid Provided by Third-Party?*
     - -

  • Vehicle Incident (VI) Notification

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  • When Did the Incident Occur?*
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  • Was the driver of Vehicle 1 hurt as a result of the incident?*
  • Select the areas damaged on Vehicle 1 as per the diagram shown below:*
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  • Was the driver of Vehicle 2 hurt as a result of the incident?*
  • Select the areas damaged on Vehicle 2 as per the diagram shown below:*
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  • Was the driver of Vehicle 3 hurt as a result of the incident?*
  • Select the areas damaged on Vehicle 3 as per the diagram shown below:*
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  • Was the driver of Vehicle 4 hurt as a result of the incident?*
  • Select the areas damaged on Vehicle 4 as per the diagram shown below:*
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  • Was a Third-Party Injured as a Result of the Incident? (e.g. Pedestrians, Public)*
  • Was Anyone Else Directly Involved or Affected by this Incident (i.e. contractors, visitors, public, etc.)?*
  • Was any Equipment Involved or Affected by this Incident (i.e. contractors, visitors, public, etc.)?*

  • Property Damage/Operational Loss

  • Property Damage / Loss Category:*
  • Was the Chemical/Fuel Spill Immediately Cleaned Up?*
  • Was the Damage Caused by a Third Party (e.g. Contractor, Visitor, Client, etc.)?*
  • Format: (000) 000-0000.

  • Near Miss / Hazard ID

  • Near Miss Category:*

  • Incident Hazard Identification

  • Select the Type of Hazard(s) that may have contributed to the incident:*
  • Is this a Newly Identified Hazard?*

  • Identify ALL factors that may have contributed to the incident.

  • Were there any Unsafe Acts that may have contributed to the incident?*
  • Were there any Unsafe Conditions that may have contributed to the incident?*
  • Were there any System Deficiencies that may have contributed to the incident?*
  • Have any Immediate Corrective Actions been taken to prevent reoccurrence?*
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  • Incident Reporter Details

  • Incident Reported Date*
     - -

  • Part 2 - Incident Investigation

  • Instructions

    1. Incident Investigations must be completed by individuals with the required incident investigation training.
    2. Investigations should be completed as soon as reasonably practicable. Begin collecting information immediately.
    3. Incident Investigations must be submitted to your manager within 48 hours from the date of the incident OR from the date of first report.
    4. Incident Investiation must be submitted by the LEAD Investigator.

     

  • Date of Investigation:
     - -

  • Affected employee statement of events and factors that may have contributed to the incident:

     

  • WCB or Injured Worker Information
  • Was there any Modified/Restricted Duty(s) required?
  • Was there time lost beyond the day of the incident?

  • Root Cause Analysis

    For every incident, a root cause analysis helps us identify system deficienies that may have contributed to the event.

    The responsible manager and/or HSE representative will review the information collected during the investgiation to determine the causal factors related to the incident.

     

    A corrective action should be assigned to address each causal factor identfied during the investigation. 

  • Direct Causes (Worker Level)

  • Substandard Practices
  • Substandard Conditions

  • Basic Causes (Supervisor Level)

  • Lack of knowledge / Skill related to...
  • Improper Motivation related to...
  • Inadequate Supervision related to...
  • Inadequate Work Standards related to...

  • Root Causes (Management Level)

  • Management failure to establish or maintain standards for...
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  • The total risk factor (TRF), is based upon the severity, liklihood for recurrence and how often the situation arises.

    On a scale of 3 - 12, with 12 being the highest risk factor and most serious.

    3-5: A minor incident with low exposure and liklihood of recurrence, requires apporpriate corrective actions within a fixed time period.

    6-8: An incident with medium risk, requires modification to processes and corrective action within a week

    9-12: An incident with serious outcomes and liklihood of recurrents, requires immediate attention and corrective actions.  

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  • IMPORTANT - In the event an incident is ongoing at the time of the investigation, be sure to maintain a record of corrective measures implemented, discussions with affected personnel and any other pertinent information as applicable to the event.

  • Incident Investigation Sign Off

  • Investigation Submission Date:
     - -

  • Part 3 - Superintendent Review

  • On review of this near miss, I confirm:*

  • If you are going to complete the investigation yourself select the investigation TAB at the top of the form.

    OR add the investigators name and email and Submit Incident Review below and the investigator will be notified.

  • Superintendent Review Date
     - -

  • Part 4 - Manager Review

  • Instructions

    1. Review the incident and investigation in Part 1 and 2.
    2. Add any additional corrective actions and comments in Part 3.
    3. Sign and Submit you Review.
  • Classification of Vehicle Incident:
  • Preventable Vehicle Incident (PVI) Grading:
  • Rows
  • Rows
  • On review of this near miss, I confirm:
  • Manager Review Date:
     - -
  • Should be Empty: