INCIDENT ANALYSIS

SYSTEM
CHALLENGES
Management

Employee:

Phone:

Employee

Date/time of Incident:
2

Detailed Form Instructions

e-mail:
Dept:

Location:
Policy enforcement
Hazard recognition
Accountability
Supervisor training
Corrective action
Production priority
Proper resources
Job safety training
Good hiring practices
Maintenance
Adequate staffing
Safety observations

Employee Report of Injury Form

Date/time First Reported:

Reported to:

Phone of reported to:

Incident Location:
3

Describe Injury or damage (nature of injury and part of body or damage):

Medcor s recommendation:

Self-treat

Refer to medical

Medcor not used

Medical Treatment Provided by:

Following procedure
Training
Previous injury
Mental ability
Physical capacity
Equipment use
Short cuts
PPE worn
Safety attitude

Yes

No

If Yes, PIT operator must be retrained prior to being allowed

to re-operate a PIT. Contract EHS to schedule the training.

PIT (forklift, tugger) involved?

Describe What Happed:

Identify factors that ARE NOT WORKING (refer to lists on left side of page):

Equipment
Tool availability
Maintenance
Visual warnings
Proper tool selection
Guarding

Management:

Employee:

Environment
Plant layout
Chemical
Temperature
Noise
Radiation
Weather
Terrain
Vibration
Ergonomics
Lighting
Ventilation
Housekeeping
Biological

Equipment:

Environment:

Additional Causal
Factors
Faulty equipment

Non-employee
Prior injury

Counter Measures/Best Practice (How do we correct areas identified in

the MEEEarea above, who will make changes, and when the changes
will be completed?)

Who?

Late reporting
Off-the-job injury
(Explain any checked
bo es on separate
sheet)

Incident Analysis Completed by:

9

Submit Form

Title:

Date of Analysis:

When?

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EMPLOYEE FIRST REPORT OF INJURY

Print Form

Employee Information
Employee Name:

Dept:

Supervisor Name:

Hire Date:

Person Completing Form:

Incident Information
Date of Injury

Time of Injury

Time Began Work

Date is Approximate

Cannot be Determined

What were you (employee) doing just before the incident occurred?

How did the injury occur?

What part(s) of the body was affected?

How was it affected?

What object or substance directly harmed you (employee)?

What is the exact location of the incident?

Were there any witnesses?

Yes

If yes, list witness names

No

Employee Signature:

Date:

Instructions for Filling Out the Incident Analysis Form

1. Section 1:
1.1. Enter the employees first and last name that was directly involved in the incident, e.g., injury
incident, material handling incident, etc.
1.2. Enter a phone number where the employee can be reached. This is in case they may be off
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work due to their injury or other reason and further information may be required from them.
1.3. Enter the employees email address. This is another way to contact them if they are off work.
1.4. Enter the Dakkota location, e.g., Holt Holloway, Louisville CMA, etc.
1.5. Enter the name of the department the employee is assigned.
2. Section 2:
2.1. Enter the date and time of the incident using mm/dd/yyyy and hh:mm am/pm format. The PDF
form will convert the date to an abbreviated month, day, year format, i.e., Aug 2, 2015.
2.2. Enter the date and time the incident was first reported.
2.3. Enter the name of the person the incident was reported to. This may have been someone other
than the person filling out the Incident Analysis form.
2.4. Enter the phone number of the person the incident was reported to.
2.5. Enter the specific location or description where the incident took place, i.e., IP line station 3,
building column D10, etc.
3. Section 3:
3.1. Describe the injury or damage caused by the incident. What body part was injured and what
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was the injury. What was damaged and how much.
4. Section 4:
4.1. Enter Medcors recommendation by checking the Self treat or the Refer to medical radio
button. If Medcor was not used check the Medcor not used radio button.
4.2. If the employee was sent out for medical treatment or evaluation, enter the name of the clinic
or hospital they were sent.
5. Section 5:
5.1. If the incident involved a Power Industrial Truck (PIT) check the Yes box, else check the No
box. If the incident did involve a PIT then the operator must be retrained in relevant topics
involved with the incident before they are allowed to operate a PIT. This is a safety law
requirement and the training must be documented. Contact your EHS to schedule the training.
6. Section 6:
6.1. Describe what happened, e.g., The employee tripped on an empty pallet that was laying on
the floor causing them to fall. Do not draw conclusions or provide opinions why it happened.
Just simply state what happened.
7. Section 7:
7.1. Every organization has systems and the primary systems of all organizations are Management,
Employee, Equipment, and Environment (MEEE). Section 7 has four boxes that represent these
organizational systems. One or more deficiencies (something that is not working) cause
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weaknesses in the system which can then lead to mishaps or events that either cause or
contribute to safety incidents.
7.2. On the left-side of the form are headings for each of the four systems. Each heading contains a
starting list of common issues found in these systems. This is only a starter; they are not to be
looked at as questions, but rather a reminder of what the systems represent.

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7.3. The only information you place in the four boxes are what is NOT WORKING in the system, not
those that are working. Do not enter into the system boxes statements like, We have a
program in place; Everyone was working safely; The equipment was guarded. Listing what
is working is not the purpose of this analysis. The purpose is to find out what is NOT working in
the system. Instead list things that are not working like, We dont have a policy for this
situation; Training was not provided; The guard was missing; The worker was taking a
risk.
7.4. Try to find at least one thing not working for each of the four boxes. The important point is that
even in the most seemingly straightforward incident there never only a single cause or root
cause. For example an analysis which concludes that an incident was due to worker
carelessness and goes no further, fails to seek answers to several important questions such as:

Was the employee distracted? If yes, why were they distracted?

Was a safe work procedure being followed? If not, why were they not followed?

Were safety devices in order? In not, why were they not in order?

Was the employee trained? If not, why were they not trained?
An inquiry that answers these and related questions will probably reveal conditions that are
more open to correction than attempts to prevent carelessness by the employee.

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7.5. Management: Management is responsible for the safety of the workplace. Therefore, the role
of supervisors, higher management and/or the presence of management systems must always
be considered in an incident analysis. Problems in organizational systems are often found to be
direct or indirect factors in incidents. Ask questions like:

Where is production on the priority list?

Is there adequate staffing?

Are there good hiring practices in place and are they being used?

Are additional supervisory skills needed?

Were safety rules communicated to and understood by all employees?

Were written procedures and orientation available and conveyed to all employees?

Were they being enforced?

Was there adequate supervision?

Were workers trained to do the work?

Was regular maintenance of equipment carried out?

7.6. Employee: The physical, mental, and decision-making process of those individuals directly
involved in the event must be explored. The purpose of analyzing the incident is NOT to
establish blame against someone, but the inquiry will not be compete unless personal
characteristics are considered. Ask questions like were workers:

Following procedure?

Taking short cuts?

Wearing PPE?

Experienced in the work being done?

Adequately trained?

Physically able to do the work?

Under stress, either work related or personal related?

7.7. Equipment: Seek out possible causes related to the equipment and materials used. Equipment
by itself does not create hazards or cause the incident. The hazard is created by its owner or
operator. Ask questions like:

Was the proper tool selected?


Was the tool available?

Was there an equipment failure?

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Was the machinery or equipment poorly designed?

Were hazardous substance involved?

Were hazardous substances clearly identified?

Was a less hazardous alternative substance possible and available?

Was the raw material substandard in some way?

Was PPE used?

7.8. Environment: The physical environment, and especially sudden changes to that environment,
are factors that need to be identified. The situation or condition at the time of the incident is
what is important, not what the usual conditions were. Environmental problems may seem
uncontrollable, but they are very important to the analysis process. For example, you may want
to know:

Was the plant or workstation layout adequate for the work?

Was there high ergonomic risk factors?

Did any part of the job cause excessive vibration to the whole body or specific body parts?

Did noise levels contribute to the incident, e.g., interfere with verbal communication or
warning signals?

Did chemicals cause unacceptable changes to the work environment, e.g., smell, smoke,
slippery surfaces, etc.? Was there a presence of toxic or hazardous gases, dusts, or fumes

Was the lighting adequate for the type of work being performed?
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Did weather conditions contribute to the incident? Rain, wind, snow, ice, heat, cold, etc.

Was there poor housekeeping practices?

7.9. Obviously there is considerable overlap between the system categories. This reflects situations
in real life. Again, the above sample questions do not make up a complete checklist, they are
Starter Fluid only.
8. Section 8: Once you have identified those things in the Management, Employee, Equipment, and
Environment (MEEE) systems that are not working, you need to find out why for each one of
them. Once the why can be reasonably determined, you can start working on the counter
measures or best practices to correct the MEEE deficiencies.
8.1. Your recommendations should:

Be specific

Be constructive

Consider organizational issues

Follow the Safety Hierarchy of Controls:

o
Eliminate or use a safe substitute (take away the hazard, provide a safe chemical,
lower speed, energy, etc.)
o
Implement engineering controls (guards, light screen, platform to replace use of
ladder, etc.)
o
Provide warnings (signs, sounds, lights, etc.)
o
Provide administrative controls (training, safe work procedures, job rotation, etc.)
o
Provide proper PPE (safety glasses, gloves, sleeves, shoes, etc.)
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Prioritize your solutions/recommendations using the high impact, low impact, easy or
difficult to implement matrix
8.2. Enter your recommendations in section 7 on the form along with who is responsible for each of
the items and the target date for implementation. The responsibility for each counter measure

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must fall to one person, by name, not multiple people or a title. If multiple people are
responsible for the same item, then no one is responsible.

9. Section 9:
9.1. Enter your name (the person completing the form), your title, and the date the analysis was
completed.
9.2. Send an email copy of the form to the local EHS Coordinator for their files.