Date:	Date.	Document ID#:	(pvid)-(cntrtrID)-(base code)-III-(yymmdd)-V(version)	Version #:
PVID#:	Contractor/Company Name:	Contractor ID:
Camp/Base:	Choose a Camp/Base	Location:	Site:

(Date and Time of Event)

(Corresponding JARS Event Number)

(Brief Event Title)

Event reported by:
Incident investigator/s
Report Author

To be completed for:

All events notifiable to WorkSafe;

Investigating complex events or trends; and

"Deep Dive" detailed investigations.

For other events use "Incident Investigation Report – (short form)"

Contents

Contents	2

1.	Executive Summary	3

1.1	Summary Findings	3

2.	Background to the Incident	3

2.1	The event	3

2.2	Event time line	3

2.3	Workers and others interviewed	3

3.	Immediate Action/s Taken	4

4.	What caused the Incident?	4

4.1	Immediate causes	4

4.2	Underlying causes	4

5.	Contributing Factors	4

6.	Key Findings	5

6.1	PEEPO Chart	5

6.2	Incident Investigation Tree	5

7.	Root Causes, Conclusion & Lessons Learnt	6

7.1	Root Cause/s	6

7.2	Conclusion	6

7.3	Lessons Learnt	6

8.	Recommendations	6

8.1	Local Level	6

8.2	Wider Organisational Level	6

9.	Incident Report Sign-off	6

9.1	Corrective Action Plan	6

9.2	Comments and Sign-off	7

10.	Appendices	7

Executive Summary

Insert a summary of the purpose of the investigation. Include key findings, root causes and recommendations for improvement. Note: the executive summary is generally the last section to be completed.

Summary Findings

Key findings of this investigation highlighted the following control measures (red = inadequate, green = adequate):

Control Measure	Status
Adequate
Inadequate

Root causes identified include:

(Root cause 1 and description):

(Root cause 2 and description):

Recommendations for Improvement include:

XXX

XXX

Background to the Incident

The event

(Describe what happened)

Event time line

S/No	Date	Time	What happened

Workers and others interviewed

Name	Position	Company / Organisation

Immediate Action/s Taken

XXX

XXX

What caused the Incident?

Immediate causes

(substandard/unsafe acts, practices or conditions)

XXX

Underlying causes

(job or personal factors)

XXX

Contributing Factors

Contributing factors highlighted in this investigation report include:

XXX

XXX

Key Findings

PEEPO Chart

People	Equipment	Environment	Procedures	Organisation

Incident Investigation Tree

Organisational Factors	Task & Environmental Conditions	Individual / Team Actions	Absent / Failed Defences	Incident

Key to ICAM Organisational Factors (highlight red):
Communication (CO)	Management of Change (MC)	Design (DE)
Hardware (HW)	Incompatible Goals (IG)	Maintenance Management (MM)
Management of Change (MC)	Management Systems (MS)	Organisation (OR)
Organisational Culture (OC)	Organisational Learning (OL)	Procedures (PR)
Regulatory Influence (RI)	Risk Management (RM)	Training (TR)
Vehicle Management (VM)

Root Causes, Conclusion & Lessons Learnt

Root Cause/s

Key findings in this investigation highlighted the following:

(Root cause 1): (description)

(Root cause 2): (description)

Conclusion

‘This incident took place as a result of….’

Lessons Learnt

Key lessons to be learnt from this incident:

XXX

XXX

XXX

Recommendations

Local Level

XXX

XXX

Wider Organisational Level

XXX

XXX

Incident Report Sign-off

Corrective Action Plan

S/No	Action	Hierarchy of Control	Responsible Person	Target Date
1
2
3

Comments and Sign-off

Comments:
Name	Signature	Date
(Contractor H&S Manager)
(Contractor Project Manager)
(Engineer to Contract)
(DEI RHSS)
(DEI DD HS)
(DEI Exec Representative)

The process for Sign-off:

Ensure the workers involved have reviewed the investigation

Sign off should include the DEI RHSS and/or DEI DD H&S, Contractor Group Safety Manager and a representative from the DEI Executive team

Appendices

Note: Some of the following items may form part of this report (add or remove as required). A Safety Alert & Lessons Learnt must be completed for all investigations and submitted to the DEI H&S office for communication to the wider organisation, where applicable.

Safety Alert (drafted and submitted to DEI RHSS)

Lessons Learnt (drafted and submitted to DEI RHSS)

Site Photos

Work Pack Instructions/diagrams

Copy of Team briefing / Tailgate

Documented Instructions, JSA’s, SWMS, etc

Permits

PEEPO Chart

Investigation Tree / 5 Why’s Template