Workplace Incident Investigation Rubric
Workplace Incident Investigation Rubric
|
Incident Details |
|
|
Date and Time |
[Month Day, Year, Time] |
|
Location |
[Warehouse B, Section 4] |
|
Brief Description |
[Forklift overturned while maneuvering in a narrow aisle.] |
|
Immediate Actions |
|
|
First Aid/Medical Treatment |
[First aid administered on-site; employee taken to hospital for further examination.] |
|
Area Secured |
[Yes] |
1. Incident Classification
Type of Incident
-
Slip, Trip, Fall
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Equipment Failure
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Other (Specify)
Severity Level
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Minor
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Moderate
-
Severe
-
Catastrophic
2. Hazard Identification
Types of Hazards
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Physical
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Chemical
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Biological
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Ergonomic
Specific Hazards Identified
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Narrow Aisles
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Improperly Stacked Inventory
3. Cause Analysis
Immediate Causes
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Human Error
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Equipment Malfunction
Underlying Causes
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Inadequate Training
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Poor Maintenance
Contributing Factors
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Environmental Conditions (Cluttered Aisles)
4. Witness Information
Witness Details
-
John Doe, Co-worker
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Jane Smith, Supervisor
Interview Summaries
-
Both witnessed the forklift struggling to maneuver before tipping over.
5. Evidence Collection
Types of Evidence
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Photographic (pictures of the scene)
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Documents (Forklift maintenance log)
6. Risk Assessment
Likelihood of Recurrence
-
High
-
Medium
-
Low
Impact on Health and Safety
-
High
-
Medium
-
Low
7. Corrective Actions
Short-term Measures
-
Reorganize inventory to widen aisles.
Long-term Solutions
-
Implement comprehensive forklift operation training.
8. Follow-Up Actions
Implementation of Recommendations
-
Completed
-
In Progress
Monitoring and Review
-
Monthly safety inspections scheduled.
9. Reporting and Documentation
Report Quality
-
Clarity
-
Completeness
Documentation
-
All Steps Documented
10. Communication and Feedback
Communication with Parties
-
Employees
-
Management
Feedback Mechanisms
-
Established
-
Effective
