KHYBERPAKHTUNKHWA-RURAL
ACCESSIBILITY PROJECT (KP-RAP)
Accident/Incident Investigation Form
Incident details
Name of person involved in the incident: Date of incident:
Location of incident:
Incident investigation team:
What task was being performed at the time of the incident?
What happened? (e.g., ‘employee tripped over box’ or ‘forklift hit wall’)
What factors contributed to the incident?
Environment: Equipment/materials:
Wrong equipment for the
Noise Layout / design Equipment failure
job
Material
/ equipment too heavy
Lighting Dust / fume Inadequate maintenance
/ awkward
Vibration Slip / trip hazard Inadequate guarding Inadequate training provided
Damaged /
Other Other
unstable floor
Work systems: People:
Hazard not No / inadequate risk Procedurenot followed / no
Drugs / alcohol
identified assessment conducted procedure exists
No / inadequate
No/ inadequate
safe work Fatigue Time / production pressures
controls implemented
procedure
Hazard not Inadequate training / Distraction / personal issues /
Change of routine
reported supervision stress
Other Lack of communication Other
Corrective actions:
What are we going
Contributing factor
to do to fix the Who When Completion date
(From above list)
problem?
Issue fixed?
Name Signature Date
Person involved in incident:
H&S Manager:
