Incident investigation report (NZ)

The incident report captures what happened and whether it is a notifiable event; the investigation report is the follow-up that finds WHY and fixes it. Use this form to reconstruct the sequence, gather evidence, get past the immediate cause to the root cause, and assign corrective actions. After a notifiable event, do not disturb the scene until WorkSafe says otherwise.

CompanySiteDate

Incident investigation report (NZ)

Company: ____________

Site: ____________

Date: ____________

Incident summary

	Date/time of incident and of this investigation: ____________	N/A · Action
	Location and project: ____________	N/A · Action
	People involved and their roles: ____________	N/A · Action
	Reference to the incident report and any WorkSafe notification: ____________	N/A · Action
	Investigation team (include a worker where possible): ____________	N/A · Action

What happened (the sequence)

	Step-by-step timeline leading up to the event	N/A · Action
	The task being performed and whether it followed the SSSP or task analysis	N/A · Action
	What was different about this day (people, plant, conditions, time pressure)	N/A · Action

Evidence gathered

	Photos of the scene and plant (scene preserved if a notifiable event)	N/A · Action
	Witness statements collected separately and promptly	N/A · Action
	Documents: SSSP, task analyses, induction and training records, SDS, plant records	N/A · Action
	Physical evidence preserved	N/A · Action

Contributing factors

	Task/procedure: was there a task analysis, was it usable, was it followed?	N/A · Action
	Plant/materials: condition, guarding, maintenance, right plant, certificates	N/A · Action
	Environment: weather, lighting, housekeeping, other PCBUs on site	N/A · Action
	People/training: competent, inducted, supervised	N/A · Action
	Systems: was the hazard identified in the SSSP, controlled, and checked?	N/A · Action

Root cause

	Ask "why" repeatedly past the immediate cause to the underlying system gap	N/A · Action
	Immediate cause (the unsafe act or condition): ____________	N/A · Action
	Root cause (the system that allowed it): ____________	N/A · Action
	Note: "the worker was careless" is not a root cause; ask why the system let it happen	N/A · Action

Corrective actions (in the hierarchy of controls)

	Elimination or substitution where possible	N/A · Action
	Isolation and engineering controls	N/A · Action
	Administrative controls (revised SSSP or task analysis, training, supervision)	N/A · Action
	PPE where still needed	N/A · Action
	Each action: owner, due date, and how completion will be verified: ____________	N/A · Action

Follow-up and sign-off

	SSSP and task analysis reviewed and revised before the work resumed	N/A · Action
	Lessons shared with the crew and other sites where relevant	N/A · Action
	Records of the notifiable event kept for at least 5 years	N/A · Action
	Investigation reviewed and signed by management: ____________ date ____________	N/A · Action

Completed by: ____________________

Signature: ____________________

swmspack.com · Free printable checklist. Not legal advice; adapt to your site.

Common questions

▸What is the difference between an incident report and an investigation?

The incident report is the immediate record: what happened, injuries, whether it is a notifiable event, and first actions. The investigation finds the root cause and sets corrective actions so it does not recur. Report first, investigate straight after.

▸Should we investigate near misses?

A serious near miss (or a notifiable incident with no injury) deserves the same investigation as an injury, because only luck separated them. Match the depth to the potential severity, not just the outcome.

▸What happens to the SSSP after an incident?

Review the SSSP and the task analysis for that work with the crew before it resumes. If the investigation finds a hazard or control was missed, revise the plan before anyone goes back.

An incident is the trigger to review the SSSP before work resumes. Regenerate a site-specific one in minutes.

Forms record the day; the SSSP is the plan the main contractor asks for before you start. Generate a site-specific one for your trade, checked against HSWA 2015.

See a sample SSSP Build my SSSP, NZ$89

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