HS1F_002 Effective: 02/28/2018

Retention Description: Manager, supervisor, or equivalent is to submit completed form via Step 7 “submit button” and retain completed form(s) as necessary.

Maintain copies of form as needed. EHS to maintain electronic version on Injury, Illness,

Exposure Reporting webpage.

HS1F_002_Incident Investigation Form Incident Date and Time: Incident Scope (Check appropriate box/boxes)

Near Miss Injury - First-Aid Injury - OSHA Recordable or Lost Work Day Illness Property Damage Loss Control – Fire, Explosion, Machinery Malfunction, etc.

Investigation Date:

Lead Investigator Name: Other Investigator(s) Name:

STEP 1: MAKE INITIAL RESPONSE AND REPORT Activate appropriate emergency response, e.g. 911, Emergency Services, Fire Department, and Police. Report the incident to supervisor and unit safety manager. Secure the scene. Ensure safety of personnel and the Cornell Community. • Preserve the scene of relevant physical items and record important information.• Take pictures of the scene and relevant equipment. Pictures should be at varying distances and angles.• Collect, identify, and store physical items and data records.• Document key personnel to interview.

Complete and Submit preliminary Injury / Illness / Exposure Report within 24 hours or less of incident.

STEP 2: FORM INCIDENT INVESTIGATION TEAM An incident investigation is required for all OSHA recordable (Medical treatment beyond first aid, e.g. Sutures/Staples/Glue, Prescriptions,

Chiropractic Care, Physical Therapy, Rigid Splints/Casts), and lost workday incidents. • First Aid and near miss incidents should be investigated if the incident could have resulted in serious injury or fatality.

For severe or complex incidents, assemble a diverse team (manager, technicians, trades, engineers, or specialists) to thoroughly investigate the incident.

STEP 3: DETERMINE THE INCIDENT FACTS Evaluate the Physical Conditions and Factors, which contributed to the incident. Consider weather conditions, chemicals, equipment, tooling, and other potential factors which contributed to the incident

Evaluate the Human Factors, which contributed to the incident. Consider the personnel(s) associated with the incident. Their behavior(s), condition(s), state of mind, training, and other potential factors, which contributed to the incident.

Evaluate the Operating Conditions and Systems, which contributed to the incident. Consider company training systems, work schedule(s), work order(s) preventative maintenance, communication, and other potential factors, which contributed to the incident.

Interview key personnel involved or connected to the incident. Ask open-ended questions, listen, take notes and periodically re-state their response(s) for clarity. List personnel names below.

STEP 4: DETERMINE THE CONTRIBUTING FACTORS Determine why the incident facts occurred by identifying the incident’s root cause(s). Select one fact associated with the incident and continue to ask “why” each subsequent fact/event occurred. This brainstorming technique known as the “5 Whys” will identify the root cause(s) of the incident to explain why the at-risk behaviors occurred or at-risk conditions existed.

HS1F_002 Effective: 02/28/2018

Retention Description: Manager, supervisor, or equivalent is to submit completed form via Step 7 “submit button” and retain completed form(s) as necessary.

Maintain copies of form as needed. EHS to maintain electronic version on Injury, Illness,

Exposure Reporting webpage.

Personal Factors: Job / System Factors: Abuse or Misuse

Intentional act condoned or not condoned by Supervision Other

Why:________________________________________________________

Cognitive State, or Stress Fear, phobia, or emotional disturbance Extreme judgment or decision demands Excessive frustration Other

Why:________________________________________________________

Physical/Physiological Aptitude Substance sensitivity or allergy Vision / Hearing deficiency Other

Why:________________________________________________________

Fitness for Duty Pre-existing Injury or Illness Fatigue due to task load or duration Fatigue due to lack of rest Constrained movement Drugs or alcohol Personal medical condition Other

Why:________________________________________________________

Improper Motivation Improper performance is rewarding Proper performance is punishing Improper attempt to avoid discomfort or gain attention Inappropriate peer pressure Improper supervisory example Inadequate performance feedback Lack of incentive, or improper incentive Other

Why:________________________________________________________

Lack of Experience or Training Lack of experience Inadequate orientation, initial or updated training Misunderstood directions Other

Why:________________________________________________________

Inadequate Instruction or Practice Inadequate initial instruction Inadequate practice Infrequent performance Lack of coaching Other

Inadequate Design or Engineering Inadequate consideration of human factors Inadequate standard, specification, and or design criteria Inadequate monitoring of initial or continued operation Inadequate assessment of operational readiness Inadequate evaluation of changes, or modifications Other

Why:________________________________________________________

Opportunity for Improvement of Leadership or Supervision Improper delegation or conflicting assignment of responsibility Giving objectives, goals or standards that conflict Inadequate instruction, orientation and or training Providing inadequate reference, and guidance documents Inadequate identification & evaluation of potential hazards Lack of supervisory/management job knowledge Inadequate performance measurement and evaluation Inadequate or incorrect performance feedback Other

Why:________________________________________________________

Inadequate Maintenance Inadequate preventative – assessment of needs, lubrication and servicing, adjustment/assembly, cleaning/resurfacing

Inadequate repair – communication of needs, scheduling work, examination/inspection of units, part substitution

Other

Why:________________________________________________________

Inadequate Purchasing Inadequate specification to given to purchasing, or vendor Inadequate research on materials/equipment Inadequate receiving inspection and acceptance Improper handling, storage, or transporting of materials Other

Why:________________________________________________________

Inadequate Tooling and or Equipment Inadequate assessment of needs or risk Inadequate human factors/ergonomics considerations Inadequate standards and specifications Inadequate availability Inadequate adjustment/repair/maintenance Inadequate removal or replacement of unsuitable items Other

Why:________________________________________________________

Wear and Tear Improper extension of service life Inadequate inspection and or monitoring Improper loading or rate of use Use by unqualified or untrained employee Other

HS1F_002 Effective: 02/28/2018

Retention Description: Manager, supervisor, or equivalent is to submit completed form via Step 7 “submit button” and retain completed form(s) as necessary.

Maintain copies of form as needed. EHS to maintain electronic version on Injury, Illness,

Exposure Reporting webpage.

Why:________________________________________________________

Inadequate Planning or Preparedness

Poor coordination or planning Routine, monotony, or preoccupied with problem Confusing, conflicting demands/directions Exposure to temperature extremes Other

Why:________________________________________________________

Other Personal Factor

Describe:_____________________________________________________

Why:________________________________________________________

Inadequate Work Standards Inadequate development of policy, procedures, or standards Inadequate communication of policy, procedures, or standards Inadequate maintenance of policy, procedures, or standards Other

Why:________________________________________________________

Other Job or System Factor Describe:_____________________________________________________

STEP 5: DETERMINE SYSTEMS TO BE STRENGTHENED In this step focus on management systems related to the key factors, the physical, human, operating systems to facilitate the development of corrective and preventative actions. Consider the following systems, Accountability, Communication, Design, Inspections, Policies, Programs, Procedures, Maintenance, Management, Supervision, Orientation, Recognition, Recordkeeping, Training, or Work Schedules.

STEP 6: DEVELOP CORRECTIVE AND PREVENTATIVE ACTIONS At least one recommendation for each contributing factor (root cause) should be identified below, in some cases; a broad recommendation may address multiple contributing factors.

Corrective Action(s) / Preventative Action(s) Implementation Date By Whom (Individual)

STEP 7: DOCUMENT AND COMMUNICATE FINDINGS Communication Plan (e.g. Toolbox Talk, Staff Meeting, Town Hall, Safety Committee, etc.):

STEP 8: FOLOW UP Establish a date and time you will follow up on the corrective and preventative actions implemented.