Section 1: Initial Response

Immediate Actions (First 60 Minutes)

• Ensure scene is safe for investigators
• Confirm injured persons are receiving care
• Secure the incident scene (barriers, signage)
• Identify and preserve evidence
• Identify witnesses
• Begin preliminary documentation (photos, notes)
• Notify required parties (management, regulators)

Evidence Preservation Log

Evidence Type	Location	Preserved By	Date/Time
Physical evidence
Documents/records
Electronic data
Photographs
Video footage

Witness List

Name	Role	Contact	Priority
			☐ High ☐ Med ☐ Low
			☐ High ☐ Med ☐ Low
			☐ High ☐ Med ☐ Low

Section 2: Incident Description

Basic Information

Field	Details
Incident Date
Incident Time
Location
Area/Department
Incident Type
Severity	☐ Fatality ☐ LTI ☐ MTI ☐ FAI ☐ Near Miss ☐ Property

What Happened?

Section 3: PEEPO Analysis

P - People Factors

Training, competence, experience, fitness, fatigue, supervision, communication

Factor	Present?	Details/Evidence
Adequate training for task	☐ Yes ☐ No ☐ ?
Competency verified	☐ Yes ☐ No ☐ ?
Sufficient experience	☐ Yes ☐ No ☐ ?
Fit for duty	☐ Yes ☐ No ☐ ?
Adequate rest/not fatigued	☐ Yes ☐ No ☐ ?
Adequate supervision	☐ Yes ☐ No ☐ ?
Clear communication	☐ Yes ☐ No ☐ ?

E - Environment Factors

Weather, lighting, noise, temperature, housekeeping, workspace layout

Factor	Condition	Contributed?	Details
Weather conditions		☐ Yes ☐ No ☐ Maybe
Lighting adequacy		☐ Yes ☐ No ☐ Maybe
Noise levels		☐ Yes ☐ No ☐ Maybe
Housekeeping		☐ Yes ☐ No ☐ Maybe
Workspace layout		☐ Yes ☐ No ☐ Maybe
Ground conditions		☐ Yes ☐ No ☐ Maybe

E - Equipment Factors

Design, condition, maintenance, guarding, PPE, tools

Factor	Assessment	Contributed?	Details
Equipment fit for purpose		☐ Yes ☐ No ☐ Maybe
Maintenance current		☐ Yes ☐ No ☐ Maybe
Pre-use inspection done		☐ Yes ☐ No ☐ Maybe
Guards/safety devices working		☐ Yes ☐ No ☐ Maybe
Correct PPE available & worn		☐ Yes ☐ No ☐ Maybe

P - Procedures Factors

Existence, quality, accessibility, clarity, compliance, permits, risk assessments

Factor	Assessment	Contributed?	Details
Procedure exists for task	☐ Yes ☐ No	☐ Yes ☐ No ☐ Maybe
Procedure followed		☐ Yes ☐ No ☐ Maybe
Risk assessment current		☐ Yes ☐ No ☐ Maybe
Permit obtained if required		☐ Yes ☐ No ☐ Maybe
JSA/JHA completed		☐ Yes ☐ No ☐ Maybe

O - Organisation Factors

Culture, management systems, resources, priorities, change management

Factor	Assessment	Contributed?	Details
Adequate staffing levels		☐ Yes ☐ No ☐ Maybe
Adequate resources		☐ Yes ☐ No ☐ Maybe
Production pressure		☐ Yes ☐ No ☐ Maybe
Safety culture		☐ Yes ☐ No ☐ Maybe
Management of change		☐ Yes ☐ No ☐ Maybe

Section 4: Root Cause Analysis (5-Whys)

5-Whys Chain #1

Contributing Factor: _________________________________

Level	Question	Answer
Why 1	Why did this happen?
Why 2	Why?
Why 3	Why?
Why 4	Why?
Why 5	Why?

Root Cause Identified: _________________________________

5-Whys Chain #2

Contributing Factor: _________________________________

Level	Question	Answer
Why 1	Why did this happen?
Why 2	Why?
Why 3	Why?
Why 4	Why?
Why 5	Why?

Root Cause Identified: _________________________________

Section 5: Corrective Actions

#	Root Cause	Action	Control Level	Owner	Due Date	Status
1						☐
2						☐
3						☐
4						☐
5						☐

Section 6: Summary & Sign-Off

Executive Summary

Key Findings

Sign-Off

Role	Name	Signature	Date
Lead Investigator
Area Manager
Safety Manager