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H&S Plan Accident/Ingiant Investigation Report Page 2 of 2 Analysis of Accident Causes Immediate Causes - Substandard Actions What substandard actions caused or could have caused the accident/incident? State the actions on the part of the employee or others that contributed to the occurrence of the accident/incident. Examples: 1) Employee overloaded the utility cart with wastepaper. 2) Employee exceeded safe speed on icy road, and was inattentive to hazard. Codes (check all that apply) 0 1. Operating equipment without authority • 5. Making safety devices inoperable • 9. Failure to use PPE properly • 13. Improper position for task 1=1 2. Failure to warn II 6. Removing safety devices 1=1 10. Improper loading • 14. Servicing equipment in operation 0 3. Failure to secure • 7. Using defective equipment 0 11. Improper placement 0 15. Horseplay 0 4. Operating at improper speed • 8. Using equipment improperly 0 12. Improper lifting 0 16. Alcohol or drug influence 0 17. Other (specify) Immediate Causes- Substandard Conditions What substandard conditions caused or could have caused the accident/incident? State the conditions that existed at the time of the accident (the specific control factors that were or may have been the direct or immediate cause or causes of the accident). Examples: 1) Wheel of utility cart was worn and would not roll properly; utility cart was overloaded with wastepaper. 2) Road was covered with icy spots; weather was foggy. Codes (check all that apply) 1. Inadequate guards or barriers • 4. Congestion or restricted action 0 7. Poor housekeeping E 10. High or low temperature exposures 2. Inadequate or improper PPE MI 5. Inadequate earning system 0 8. Noise exposures MI 11. Inadequate or excess illumination 3. Defective tools, equipment, or materials M 6. Fire and explosion hazards 0 9. Radiation exposures • 12. Inadequate ventilation E 13. Hazardous environ. conditions (vapors, dusts, etc.) 14. Other (specify) Basic Causes - Personal and Job Factors What personal and/or job factors caused or could have caused the accident/incident? State the influencing factors or underlying causes, either conditions or actions or both, that contributed to the accident/incident. Examples: 1) Employee had not been instructed in overloading hazards. 2) Employee had not been trained in driving under winter conditions; company has no driver training program. Codes (check all that apply) Personal Factors 1. Inadequate capability • 2. Lack of knowledge 0 3. Lack of skill U 4. Improper motivation 5. Other (specify): Job Factors 1. Inadequate leadership/supervision • 2. Inadequate engineering • 3. Inadequate purchasing 0 4. Inadequate maintenance 0 5. Inadequate tools/equipment 0 6. Inadequate work standards/procedures II 7. Inadequate Wear and tear • 8. Abuse or misuse D 9. Other (specify): Remedial Actions Describe the actions taken or planned to prevent recurrence of accident/incident - provide the implementation date and person responsible for any planned corrective action.. Examples: 1) Wheels of utility cart were replaced with larger size wheels; all carts were inspected for safe operation; employees were instructed in overloading hazards. 2) All project personnel were instructed at the safety training meeting on driving under hazardous conditions; driver training program will be implemented. Codes (check all that apply) Job Factors 0 1. Reinstruction of personnel involved 0 2. Reprimand of personnel involved 0 3. Temporary/permanent reassignment of personnel 0 4. Action to improve clean-up 5. Equipment repair or replacement 06. Improve design 0 7. Improve construction 08. Improve PPE 0 9. Install of safety guard or device 0 10. Work method change 0 11. Order use of safer materials 0 12. Regional Safety Unit Manager Review 13. Other (specify): Distribution. Original - Office Health and Safety Coordinator; Copy #1 - Originator HS-19 REV. 06/2006