Page 55 - On Call folder

SF001
Accident Investigation Form Issue 1
03/09/2012

16. Causes

Immediate Causes (please tick most applicable boxes) ✓
Substandard Acts Substandard Conditions
1. Fighting / horseplay 1. Adverse underfoot conditions
2. Ignoring / disregarding warning / hazard 2. Adverse visibility
3. Inadequately performed maintenance task 3. Adverse weather conditions
4. Inappropriate / inadequate clothing 4. Congestion or restricted action / access / egress
5. Inappropriate loading / securing of vehicle 5. Defective infrastructure
6. Inappropriate placement / positioning 6. Defective vehicle / tool / equipment / material
7. Inappropriate use of Personal Protective Equipment 7. Inadequate / excessive illumination
8. Inappropriate use to tool / equipment / vehicle 8. Other hazardous environmental conditions
9. Incorrect manual handling 9. Other substandard condition
10. Maliciousness
11. Miscommunication
12. Misjudgement
13. Observance of rules / instructions / SSoW
14. Other inadequate performance of duties
15. Other inappropriate use of tool
16. Other substandard act
17. Servicing / monitoring of – when in operation
18. Taking inappropriate route
19. Use of – without authority
20. Use of – improperly
21. Use of – inappropriate for task
22. Use of – when defective
Others: Others:

Basic or Underlying Causes (please tick most applicable boxes) ✓
Substandard Acts Substandard Conditions
1. Improper motivation 1. Abuse or misuse
2. Inadequate mental / psychological capabilities 2. Inadequate engineering
3. Inadequate physical / psychological capabilities 3. Inadequate maintenance
4. Lack of knowledge 4. Inadequate purchasing
5. Lack of skill 5. Inadequate tool / equipment / material
6. Stress – mental / psychological 6. Inadequate work standards
7. Stress – physical / psychological 7. Wear and tear
8. Insufficient/ incorrect information Others:
Others:

Page 1 of 6
Please send all completed forms back to PHoSS Page 5 of 6
S:\Resource Management\On-Call\On-Call Folder 5.6.18\9. AccidentIncident Near Miss Reporting & Investigation\SF001 Accident Investigation Form Issue No 01 03-09-2012.docP Page 5 of 6
Uncontrolled copy once printed from its electronic source