Free Fillable Template

Incident Investigation Report Template

A complete, ICAM-aligned investigation report you can fill in your browser, then print or save as PDF. Covers every phase from incident details to corrective action sign-off.

✓ Incident Details ✓ Immediate Cause ✓ PEEPO Analysis ✓ Absent Defences ✓ Corrective Actions ✓ Sign-off ✓ Printable PDF

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1

Incident Details

Basic classification and location information

2

Incident Description

What happened — factual, chronological, no conclusions

3

Immediate Cause

The direct action or condition that caused harm — NOT the root cause

Barriers or controls that should have prevented harm but were absent, failed, or bypassed.

4

Contributing Factors (PEEPO)

Conditions that enabled the incident — the full causal picture

P — People
E — Environment
E — Equipment
P — Procedures
O — Organization
5

Root Causes

Underlying organizational or systemic failures — if fixed, would prevent recurrence

Root causes are systemic — typically management systems, organizational culture, resource constraints, or design failures. "Human error" is not a root cause.

6

Corrective Actions

What will be done, by whom, and by when

Prioritize elimination and engineering controls over administrative and PPE. Every root cause should have at least one corrective action.

Action Description Responsible Person Due Date Priority Status
7

Lessons Learned

Key learnings to share with the broader organization

8

Sign-Off

Investigation team authorization

Signature: ___________________________
Signature: ___________________________
Signature: ___________________________
Signature: ___________________________

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