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Describe who was involved, when and where the incident happened, what happened, and how.) Company Name/Logo: Incident Reporting and Investigation Form 10/12/10, Page 2of 3 Why did it happen (Root Cause Analysis) (What was the root cause of the incident, i.e., actually caused the illness, injury, or incident ) Unsafe Acts Unsafe Conditions Management System Deficiencies Improper Work Technique Poor Workstation Design or Layout Improper PPE, Not Used or Used Incorrectly Fire or Explosion Hazard  Safety Rule Violation Congested Work Area Operating Without Authorization Hazardous Substances Failure to Warn or Secure Inadequate Ventilation Operating at Improper Speeds Improper Material Storage By-Passing Safety Devices Improper Tool or Equipment Guards Not Used Insufficient Job Knowledge Improper Loading or Placement Slippery Conditions Improper Lifting Poor Housekeeping Servicing or Adjusting Machinery in Motion Excessive Noise Horseplay Inadequate Guarding of Hazards Drug or Alcohol Use Defective Tools/Equipment Unsafe Act(s) of Others Insufficient Lighting Unnecessary Haste Inadequate Fall Protection Other: Other: Lack of Written Procedures or Safety Rules Safety Rules Not Enforced Hazards Not Identified PPE Unavailable Insufficient Worker Training Insufficient Supervisor Training Improper Maintenance Inadequate Supervision Insufficient Job Planning Inadequate Hiring Practices Poor Process Design Inadequate Workplace Inspections Inadequate Equipment Unsafe Design or Construction Unrealistic Scheduling Other: List immediate actions taken and results..

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Construction Incident Investigation Report

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