Project/Preliminary Incident Investigation Form.docx Preliminary Incident Investigation Form Workplace Safety and Health Program A. Injured Employee DataEmployee Name Employee Age Years of Service Work Organization/Location Date of accident Time of Accident Regular Shift, day? night? other? |_| a.m. |_| p.m. Primary Language Spoken Work Telephone Other/Cell Number Supervisor B. Incident Description – Proximate Causes Instructions: What happened? What caused the accident? What were the contributing factors? Reconstruct the sequence of events that led to the injury. Attach additional sheets if necessary. This document becomes an official accounting of the facts surrounding the accident. When documenting the facts, include answers to the following questions: 1. Wheredid the accident happen and who was involved? Provide a full description of the surroundings of the location and the individuals involved. 2. What was happening at the time of the accident and why was it taking place? 3. What were the events leading up to the accident? Describe the sequence in order and when they took place. 4. What exactly caused the injury and how did it happen? What were the mechanics, equipment, or tools involved? 5. Describe the injury or injuries that incurred. What body part and what kind of injury? (Indicate if no injury occurred.) 6. After review of all facts, what was the hazardous condition, unsafe work practice, or other causal factors (procedure, equipment, people, and environment) that contributed to the accident / injury? C. Root Causes - Speculate about what factors in the Management System might have contributed to the accident. You do not have all the facts, but you can begin asking questions. What “why” questions might you ask? (Remember, you have lots of materials to give you hints about what part of the management system might have contributed to the accident.) Refer to your attachment “Root Cause Analysis.” I need to see at least 10 why questions. D. Areas of Investigation – Describe where you will begin your investigation based on the “why” questions above. I need to see at least one area of investigation for each “why” question. (Use next page, too) Preliminary Incident Investigation Form Workplace Safety and Health Program A. Injured Employee Data Employee Name Employee Age Years of Service Work Organization/Location Date of accident Time of Accident Regular Shift, day? night? other? a.m. p.m. Primary Language Spoken Work Telephone Other /Cell Number Supervisor B. Incident Description – Proximate Causes Instructions: What happened? What caused the accident? What were the contributing factors? Reconstruct the sequence of events that led to the injury. Attach additional sheets if necessary. This document becomes an official account.

1. Project/Preliminary Incident Investigation Form.docx
Preliminary Incident Investigation Form
Workplace Safety and Health
Program
A. Injured Employee DataEmployee Name
Employee Age
Years of Service
Work Organization/Location
Date of accident
Time of Accident
Regular Shift, day? night? other?
|_| a.m.
|_| p.m.
Primary Language Spoken
Work Telephone
Other/Cell Number
Supervisor
B. Incident Description – Proximate Causes
Instructions: What happened? What caused the accident?
What were the contributing factors? Reconstruct the sequence of
events that led to the injury. Attach additional sheets if

2. necessary. This document becomes an official accounting of the
facts surrounding the accident. When documenting the facts,
include answers to the following questions:
1. Wheredid the accident happen and who was involved?
Provide a full description of the surroundings of the location
and the individuals involved.
2. What was happening at the time of the accident and why was
it taking place?
3. What were the events leading up to the accident? Describe
the sequence in order and when they took place.
4. What exactly caused the injury and how did it happen? What
were the mechanics, equipment, or tools involved?

3. 5. Describe the injury or injuries that incurred. What body part
and what kind of injury? (Indicate if no injury occurred.)
6. After review of all facts, what was the hazardous condition,
unsafe work practice, or other causal factors (procedure,
equipment, people, and environment) that contributed to the
accident / injury?
C. Root Causes - Speculate about what factors in the
Management System might have contributed to the accident.
You do not have all the facts, but you can begin asking
questions. What “why” questions might you ask? (Remember,
you have lots of materials to give you hints about what part of
the management system might have contributed to the accident.)
Refer to your attachment “Root Cause Analysis.” I need to see
at least 10 why questions.

4. D. Areas of Investigation – Describe where you will begin your
investigation based on the “why” questions above. I need to see
at least one area of investigation for each “why” question. (Use
next page, too)
Preliminary
Incident
Investigation Form
Workplace Safety and Health Program
A. Injured Employee Data
Employee Name

5. Employee Age
Years of Service
Work Organization/Location
Date of accident
Time of Accident
Regular Shift, day? night?
other?
a.m.
p.m.
Primary Language Spoken
Work Telephone
Other
/Cell Number

6. Supervisor
B.
Incident
Description
–
Proximate Causes
Instructions:
What happened? What caused the accident? What
were the contributing factors? Reconstruct the
sequence of events that led to the injury. Attach additional
sheets if necessary. This document becomes an official
accounting of the facts surrounding the accident. When
documenting the facts, include answers
to the following
questions:
1.
Where
did the accident happen and who was involved? Provide a full
description of the surroundings of the location
and the individuals involved.

7. 2.
What was happening at the time of the accident and why was it
taking
place?
3.
What were the events leading up to the accident? Describe the
sequence in order and when they took place.
4.
What exactly caused the injury and how did it happen? What
were the mechanics, equipment, or tools involved?

8. Preliminary Incident Investigation Form
Workplace Safety and Health Program
A. Injured Employee Data
Employee Name Employee Age Years of Service
Work Organization/Location
Date of accident Time of Accident Regular Shift, day? night?
other?
a.m.
p.m.
Primary Language Spoken Work Telephone Other/Cell Number
Supervisor
B. Incident Description – Proximate Causes
Instructions: What happened? What caused the accident?
What were the contributing factors? Reconstruct the
sequence of events that led to the injury. Attach additional
sheets if necessary. This document becomes an official
accounting of the facts surrounding the accident. When
documenting the facts, include answers to the following
questions:
1. Where did the accident happen and who was involved?
Provide a full description of the surroundings of the location
and the individuals involved.

9. 2. What was happening at the time of the accident and why was
it taking place?
3. What were the events leading up to the accident? Describe
the sequence in order and when they took place.
4. What exactly caused the injury and how did it happen? What
were the mechanics, equipment, or tools involved?
Project/ROOT CAUSE ANALYSIS.docxROOT CAUSE
ANALYSIS
Root cause analysis is a process by which we uncover the

10. causes which contributed to an incident in the workplace. There
are 2 kinds of causes: proximate causes and root causes.
Proximate causes are those immediate factors of the incident
which lead to an unacceptable result. Root causes are those
organizational factors that are ultimately responsible for the
incident. ROOT CAUSES ARE ALWAYS A RESULT OF
DEFECTS OR OMISSIONS IN THE MANAGEMENT
SYSTEM.
In the old style of safety, our accident investigations focused on
blaming the worker. Even though that seems like a good idea
(it’s easy and we don’t have to think about it much), it doesn’t
help us prevent accidents or save workers’ comp costs. The
only way we can prevent similar incidents in the future is to
understand the underlying causes of accidents so that we can
design the workplace to be Bubba-proof. You know Bubba. If
there is any way to mess up, Bubba will find it. Our job is to
make sure the easiest choice is the SAFEST ONE.-----------------
---------------------------------------------------------------------------
-----------------------------Here is an example:
An incident happens: A man on the night shift uses a screw
driver to pry brads out of a piece of wood. One of the brads
comes off and hits him in the eye. Let us investigate the same
accident in 2 different ways.
I. Old style incident investigation:
Cause of accident:
1. Worker used the wrong tool to do the job.
2. Worker should have been wearing PPE.
Corrective actions:
1. Told worker to use the correct tool to do the job
2. Told worker to wear PPE
II. Modern safety practice:

11. Proximate cause of incident:
1. Screw driver was used instead of brad puller
2. No PPE was worn
Root causes:
1. The correct tool (brad puller) was not available to worker at
the time his Supervisor said to do the job. Upon investigation,
it was learned that people in the area routinely used unapproved
tools to do jobs because the tool crib was not open all night.
2. Safety glasses were available to worker, but they were not
used. At interview, worker stated that people in the area often
did not wear safety glasses because the brand available wasn’t
comfortable and that they fogged up.
Corrective actions:
1. After an extensive investigation interviewing Supervisors,
Managers, looking at old records of incidents, and examining
the tool crib area, it was determined that it was cost effective to
keep one person manning the tool crib at night (there had been
similar incidents because of using the wrong tools)
2. The worker involved in the incident and other workers and
representatives of management got together to review all PPE
for adequacy and ease of use. Several changes were made.
3. All Supervisors were made aware of the changes and were
counseled to support workers taking the time to get correct tools
and were tasked to monitor the use of new safety glasses
carefully.
Let’s compare the two approaches:
In the old style of incident investigation, we blame the
worker and put the burden of any changes upon him. Is this
going to work for us? If the correct tools are not available for
him, how is he going to choose the correct tool? If safety

12. glasses are uncomfortable he probably should wear them
anyway, but he probably won’t. Why not make it easier for him
to comply? Remember, the object of the investigation is not to
find someone to blame. It is to prevent future incidents from
happening.
In the old style of incident investigation, have we
prevented more similar incidents from happening to anyone
else? Have we even prevented the incident from happening to
the same guy? The answer is NO!
---------------------------------------------------------------------------
----------------------------------------------In finding root causes
we ask the question, WHY?
Why didn’t the worker use the correct tool? Answer: It
wasn’t available.Why wasn’t it available?Answer: The tool crib
was closed at night.
Why was the tool crib closed at night?
Answer: To save money.
Is it worth the money saved to have the correct tools available?
Let’s find out! (Here’s something I can do to go about fixing
the problem!!!!) I’ll do a cost/benefit analysis to see if similar
incidents would be worth the salary for someone to man the tool
crib at night. I found that the workers’ comp costs for similar
incidents was about $150,000 last year! Eight extra hours
salary/week to man the tool crib would certainly be less then
that………….
---------------------------------------------------------------------------
-----------------------------------------------------------
Factors in the management system that you might think
about changing include poor or inadequate supervision,
emphasis on production instead of safety, inadequate training,
poor job assignment, failure to maintain equipment, poor
employee screening, not being responsive to employee
feedback. There are a million other factors of management!

13. Let’s see what you can think of………
ROOT CAUSE ANALYSIS
Root cause analysis is a process by which we uncover the
causes which contributed to an incident in the
workplace. There are 2 kinds of causes: proximate causes and
root causes. Proximate causes are those
immediate factors of the
incident which lead to an unacceptable result. Root causes are
those organizational
factors that are ultimately responsible for the incident. ROOT
CAUSES ARE ALWAYS A RESULT OF
DEFECTS OR OMISSIONS IN THE MANAGEMENT
SYSTEM.
In the old style of safety, o
ur accident investigations focused on blaming the worker. Even
though
that seems like a good idea (it’s easy and we don’t have to think
about it much), it
doesn’t help us
prevent accidents or save workers’ comp costs.
The only way we can prevent simila
r incidents in the future is to understand the
underlying causes
of
accidents so that we can design the workplace to be Bubba
-
proof. You know Bubba. If there is any

14. way to mess up, Bubba will find it. Our job is to make sure the
easiest choice is the SAF
EST ONE.
---------------------------------------------------------------------------
----------------------------------------------
Here is an example:
An
incident
happens
:
A m
an
on the night shift
uses
a
screw driver to pry brads out of a piece of wood.
One of the brads comes off and hits him in the eye.
Let us investigate the same accident in 2 different
ways.
I.
Old style incident investigation:
Cause of accident:
1.

15. Worker used the wrong tool
to do the job
.
2.
Worker should have been wearing PPE.
Corrective action
s
:
1.
Told worker to use the correct tool to do the job
2.
Told worker to wear PPE
II.
Modern safety practice:
Proximate cause of incident:
1.
Screw driver was used instead of brad puller
2.

16. No PPE was worn
Root causes:
1.
The correct tool (brad puller) was not available to worker at the
time his Supervisor said
to do the job. Upon investigation,
it was learned that
people in the area routinely used
unapproved tools
to do jobs because
the tool crib was not open all night.
2.
S
afety glasses were available to worker, but they were not used.
At interview, worker
stated that
people in the area often did not wear safety glasses
because the brand available
wasn’t comfortable
and that
they fogged up
.
Corrective actions:

17. 1.
After an ext
ensive investigation interviewing Supervisors, Managers,
looking at old
records of incidents, and examining the tool crib area, it was
determined that it was cost
effective to keep one person manning the tool crib at night
(there had been similar
incidents
because of using the wrong tools)
2.
The worker involved in the incident and other workers and
representatives of
management
got together to review all PPE for adequacy and ease of use.
Several
changes were made.
3.
A
ll Supervisors
were made
aware of the chang
es and w
ere counseled to
support workers
taking the time to get correct tools and w
ere tasked to
monitor the use of new safety

18. glasses carefully.
ROOT CAUSE ANALYSIS
Root cause analysis is a process by which we uncover the
causes which contributed to an incident in the
workplace. There are 2 kinds of causes: proximate causes and
root causes. Proximate causes are those
immediate factors of the incident which lead to an unacceptable
result. Root causes are those organizational
factors that are ultimately responsible for the incident. ROOT
CAUSES ARE ALWAYS A RESULT OF
DEFECTS OR OMISSIONS IN THE MANAGEMENT
SYSTEM.
In the old style of safety, our accident investigations focused on
blaming the worker. Even though
that seems like a good idea (it’s easy and we don’t have to think
about it much), it doesn’t help us
prevent accidents or save workers’ comp costs.
The only way we can prevent similar incidents in the future is
to understand the underlying causes of
accidents so that we can design the workplace to be Bubba-
proof. You know Bubba. If there is any
way to mess up, Bubba will find it. Our job is to make sure the
easiest choice is the SAFEST ONE.
---------------------------------------------------------------------------
----------------------------------------------
Here is an example:
An incident happens: A man on the night shift uses a screw
driver to pry brads out of a piece of wood.
One of the brads comes off and hits him in the eye. Let us
investigate the same accident in 2 different
ways.

19. I. Old style incident investigation:
Cause of accident:
1. Worker used the wrong tool to do the job.
2. Worker should have been wearing PPE.
Corrective actions:
1. Told worker to use the correct tool to do the job
2. Told worker to wear PPE
II. Modern safety practice:
Proximate cause of incident:
1. Screw driver was used instead of brad puller
2. No PPE was worn
Root causes:
1. The correct tool (brad puller) was not available to worker at
the time his Supervisor said
to do the job. Upon investigation, it was learned that people in
the area routinely used
unapproved tools to do jobs because the tool crib was not open
all night.
2. Safety glasses were available to worker, but they were not
used. At interview, worker
stated that people in the area often did not wear safety glasses
because the brand available
wasn’t comfortable and that they fogged up.
Corrective actions:
1. After an extensive investigation interviewing Supervisors,
Managers, looking at old
records of incidents, and examining the tool crib area, it was
determined that it was cost
effective to keep one person manning the tool crib at night

20. (there had been similar
incidents because of using the wrong tools)
2. The worker involved in the incident and other workers and
representatives of
management got together to review all PPE for adequacy and
ease of use. Several
changes were made.
3. All Supervisors were made aware of the changes and were
counseled to support workers
taking the time to get correct tools and were tasked to monitor
the use of new safety
glasses carefully.
Project/SPECIAL PROJECT.docxSPECIAL PROJECT
Your special project involves making decisions about
hazards; it involves ranking hazards by risk and doing an
accident investigation. You must follow these instructions
exactly for full credit.
The project is worth 50 points. You are to type up all
results and fill out your Incident Investigation form and submit
it on your Final Project Dropbox. The title page should include
SPECIAL PROJECT, the name of the course, your name and
date. Each section should be typed separately with a title page,
for example, “PART I RANKING HAZARDS BY RISK.” Use
12 point font.
Grading: your Special Project will be graded by
1. Conformance with assignment instructions 35%
2. Neatness and spelling and grammar 15%
3. Thoroughness of conclusions and recommendations 50%
PART I - RANKING HAZARDS BY RISK
Rank these hazards below by risk according to Chapter 6
Dropbox, Part 2 and your Chapter 6. (Please read it carefully,
especially if you didn’t do well in your Dropbox assignment.)
Type another page as a letter to your boss explaining which

21. hazard you should tackle in order and why. Remember, safety
is an art as well as a science. You should have at least ¾ page
of narrative. At this stage, do not use cost as a consideration.
You are the safety manager at a facility in Borger, Texas. You
manufacture pipeline for the oil field. Your first task is to
identify hazards in the facility. The facility has approximately
400 workers.
After you have identified hazards you come up with the
following list:
1. Exposed electrical wires on the conveyor belt.
Approximately 20 workers work around the conveyor belt every
day. The exposed wires are not really near to their work area,
but if they dropped something, they might brush against them.
2. One of the stamping machines leaks oil. Approximately 30
workers have direct contact with the floor every day. They do
wear non-slip boots, but the boots don’t always work to prevent
slipping.
3. Some of the lights are burned out in one section of the plant
where 200 workers work all the time. The tasks they perform
are not detailed, but sometimes they have trouble seeing
potential hazards on the floor.
4. In the basement there are pipes overhead about 5 feet from
the ground. About 25 workers have to pass under the pipes
every week or so because the aisle runs directly under the pipes.
5. Two workers work with corrosive chemicals that can burn
skin badly. The containers in which the corrosive containers
are stored are not labeled properly. They work every day.

22. PART II - INCIDENT INVESTIGATION AND ANALYSIS
When an accident occurs, the Supervisor usually completes the
initial investigation; however, as Safety Officer, the final
investigation and the recommended countermeasures are your
responsibility.
Based on a thorough reading of your Chapter 10, complete the
following case study. You should use the incident investigation
form attached. If you do not know the information in the
blanks, type “N/A”. You may need additional sheets to write
your causal factors and corrective actions. Use the information
in Chapter 10 to suggest some avenues for further investigation
since you do not have all the facts yet. (Often you will be
asked to submit a preliminary report before you have done a
thorough analysis. In the Causal Factors and Corrective
Actions section, you are to have two separate sections:
“Proximate Factor” and “Root Cause Factors.” Think about
factors of the person, environment, management, and equipment
for Proximate Factors and management system flaws for your
Root Cause Factors.
________________________________________________
You are the Safety Manager for a small manufacturing
company. You make cardboard containers. You have
approximately 250 employees. Your plant is about 30 years old.
The average age of your workforce is 40. Some of your

23. employees have been there for 25 years or more. You have 25
% female employees and 15 % non-English speaking. You are a
Union shop. Your plant is divided into 4 work areas and 2
shifts with different supervision in each area and shift. The
shifts are from 7:00 – 7:00.
Accident Investigation
You receive a call at your home at 3:00 a.m. explaining
that Alejandro Garcia, full-time employee on the night shift has
been seriously hurt. He was cleaning out the cardboard feeder
in the packaging area when the feeder started up again severing
two of his fingers on his right hand. In addition, he sprained
his neck trying to free his hand. Alejandro has been on the job
for 6 months. He is 20 years old. His Supervisor Steve
Anderson has had more accidents in his department than any
other Supervisor. You have smelled alcohol on Alejandro’s
breath on one occasion, but you have no other evidence that
Alejandro is a drinker.
You rush to the plant. You cannot interview the employee
since he was sent to St. Anthony’s hospital, but your boss
insists that you provide him with a preliminary report by the
morning.
You survey the scene. Here is what you learn:
1. The safety on the cardboard feeder than Alejandro was
working on had been tampered with by the insertion of a penny
in the automatic stop, which prevented the automatic stop from
working.
2. The automatic stop was supposed to have received periodic

24. maintenance but the records were not found.
3. The Supervisor did not find Alejandro for 20 minutes even
though Alejandro had been yelling
4. There is only one Supervisor in the area due to budget
cutbacks
5. Alejandro’s training records are incomplete, and you can’t
tell when he was trained the last time to do his job.
6. The employee has had numerous accidents since he has been
here.
7. Lockout/tagout procedures had been written, but
lockout/tagout was not used.
8. Alejandro was supposed to have a helper, but the helper
called in sick, and no one else was there to replace him.
SPECIAL PROJECT
Your special project involves making decisions about hazards;
it involves ranking hazards by risk
and
doing an accident
investigation.
You must follow these instructions exactly for full
credit.
The project is worth
50
points. You are to type up all results
and fill out your Incident Investigation form and submit it on
your Final

25. Project Dropbox.
The title page should include SPECIAL PROJECT,
the name of the course,
your name
and date. Each section should be
typed se
parately with a title page, for example, “PART I
RANKING
HAZARDS BY RISK.” Use
12 point font.
Grading: your Special Project will be graded by
1.
Conformance
with assignment instructions
3
5%
2.
Neatness and spelling and grammar
15%

26. 3.
Thoroughness of
conclusions and recommendations
50
%
SPECIAL PROJECT
Your special project involves making decisions about hazards;
it involves ranking hazards by risk and doing an accident
investigation. You must follow these instructions exactly for
full
credit.
The project is worth 50 points. You are to type up all results
and fill out your Incident Investigation form and submit it on
your Final
Project Dropbox. The title page should include SPECIAL
PROJECT,
the name of the course, your name and date. Each section
should be
typed separately with a title page, for example, “PART I
RANKING
HAZARDS BY RISK.” Use 12 point font.
Grading: your Special Project will be graded by
1. Conformance with assignment instructions 35%
2. Neatness and spelling and grammar 15%
3. Thoroughness of conclusions and recommendations 50%