Section J_Technical Exhibit K. Incident Investigation Form WJHTC TEMPLATE.pdf

Employee Type: Contractor Federal: Outside Vendor: Visitor: Other:

EOSH Program: OSHA Recordable:

Near Miss: Injury/Illness: 1st Aid:

Property Damage:

Environmental (Spill/Release):

Motor Vehicle: Non‐Work Related:

Last: First:

Manager:

(Describe actual incident, any events leading up to it (including behavioral aspects), and possible causes.

Witness:

Date of Incident: Time of Incident:

2. EMPLOYEE NAME and INFORMATION:

Injury/Illness Type:

Routing Number: Job Title:

Employee Name:

Location of Incident:

3. INCIDENT DESCRIPTION:

Line of Business:

ECN #:

1. INCIDENT CLASSIFICATION:

WJHTC INCIDENT REPORT FORM

Investigative Considerations (circle states and errors identified during the investigation) Behavioral Safety Factors:

CHECK STATES AND ERRORS

Four States Critical Errors Rushing Eyes not on Task Frustration Mind not on Task Fatigue Line-of-Fire Complacency Balance Traction Grip

Root Cause

Preventative Actions/ Incident Investigation Results (Actions Needed to prevent further incidents)

4. CORRECTIVE ACTIONS: (Immediate actions taken)

Date Completed Assigned toCorrective Action

Last:

Employee Name:

First:

Phone Number:

Email:Job Title:

Date of Investigation:

Investigated by:

Near Miss — An unplanned, undesired condition/ event that did not result in injury, illness, damage, but had the potential to do so.

Injury — An abnormal condition or disorder including cases such as, but not limited to, a cut, fracture, sprain, or amputation.

Illness - An abnormal condition or disorder including both acute and chronic illness, such as, but not limited to, a skin disease, respiratory disorder, or poisoning

Property Damage — An incident when one or more FAA-owned/leased, or GSA controlled, facilities, systems, equipment, or other personal or real property had been damaged.

Motor Vehicle Incident — A situation when damage occurs to an FAA-owned/leased, or GSA controlled, government motor vehicle, or to privately owned vehicle (POV) used on official FAA business and vehicles driven by FAA personnel under temporary duty (TDY) conditions are considered on-duty.

Notes:

Root Cause: