Document Document Title: Effective Date: Revision No.

&
Type: SHE 10/ 2024 Date
Form Investigation 10/ 2025
Form

Document No: Prepared BY: Approved By:

K OKE-SHEQ- SHEQ Manager CEO
006

Accident/Incident No.:

Date of Incident/Accident:

Area of occurrence:

Date of Investigation: ………………………………………

Investigators’ Name Job title Investigators’ Signature

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Assisted By:
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 Document Document Title: Effective Date: Revision No.&
Type: SHE 10/ 2024 Date
Form Investigation 10/ 2025
Form

Document No: Prepared BY: Approved By:

K OKE-SHEQ- SHEQ Manager CEO
006

INTERNAL INCIDENT INVESTIGATION (SHE)

DATE OF INCIDENT: TIME OF INCIDENT:
NAME OF PERSON INVOLVED: CO.NO: AGE:
DEPARTMENT: REGULAR OCCUPATION:
YEARS OF COMPANY SERVICE: PERIOD IN PRESENT JOB:
NAME OF SUPERVISOR: NAME OF DEPARTMENT HEAD:
1 SAFETY INCIDENT CLASSIFICATION: F  LTI  MTC  FAC  NEAR MISS
PART OF THE BODY HEAD NECK EYE TRUNK FINGER HAND
AFFECTED ARM TOE FOOT LEG INTERNAL MULTIPLE
SPRAINS STRAINS CONTUSION WOUNDS FRACTURES BURNS
EFFECT ON PERSON
AMPUTATION SHOCK ASPHYXIATION UNCONSCIOUS POISONING MULTIPLE
NATURE OF INJURY
(Describe the injury e.g. laceration left
hand index finger.)

2 DAMAGE INCIDENT
CLASSIFICATION: MAJOR VEHICLE PROPERTY DAMAGE  MINOR VEHICLE PROPERTY DAMAGE 
MAJOR PROPERTY DAMAGE  MINOR PROPERTY DAMAGE  NEAR MISS 
MVA THEFT VANDALISM WEAR & TEAR CIVIL UNREST STRIKE
MAN CAUSED FIRE FORKLIFT OTHER – SPECIFY:  Rail Locator (train)
FLOOD CYCLONE EARTHQUAKE STRONG WIND HAIL/RAIN LIGHTING
NATURAL CAUSES
OTHER – SPECIFY: 

3 HEALTH INCIDENT (INCLUDING OVER-EXPOSURE) CLASSIFICATION: F  IDD  RDD 

OCCUPATIONAL PHYSICAL BIOLOGICAL CHEMICAL ERGONOMICAL PSYCHOLOGICAL
STRESSOR
NATURE OF DISEASE
(Describe)
RESULT: TRANSFER-
FIT – RETURN TO CURRENT JOB TRANSFER-TEMP. PERMANENTLY DISABLED FATAL
PERM.

4 ENVIRONMENTAL INCIDENT CLASSIFICATION: LEVEL 3  LEVEL 2  LEVEL 1  NEAR MISS 

INCIDENT TYPE (Tick on the box before the description) INCIDENT CONSEQUENCE (Tick on the box before the
description)
CONTAINED EMISSION/DISCHARGE POLLUTION
UNCONTAINED EMISSION/DISCHARGE LEGAL NON-COMPLIANCE
CONTROLLED EMISSION/DISCHARGE PERMIT REQUIREMENTS EXCEEDED
NON-CONFORMANCE WITH CORPORATE STANDARD OR
UNCONTROLLED EMISSION/DISCHARGE
POLICY
EXCESSIVE RESOURCE USE FINANCIAL CONSEQUENCE
INAPPROPRIATE MANIPULATION OF THE ENVIRONMENT COMMON LAW CLAIM
EXCESSIVE WASTE GENERATION AND/OR DISPOSAL NUISANCE TO PUBLIC OR COMMUNITY
COMPLAINT/UNDESIRED PUBLIC OR MEDIA ATTENTION DAMAGE TO PUBLIC OR COMMUNITY
ENVIRONMENTAL DAMAGE – NATURAL SOCIO-ECONOMIC DISRUPTION
ENVIRONMENTAL DAMAGE – HUMAN ECOLOGICAL STRESS OR DAMAGE
OTHER: RESOURCE DEPLETION
CLIMATIC CHANGE
NEGATIVE PUBLICITY
ALTERATION OF PHYSICAL ENVIRONMENT
OTHER:
SEVERITY OF ENVIRONMENTAL INCIDENT:
STATE OF POLLUTANT e.g., solid, liquid, etc. (print) QUANTITY OF POLLUTANT e.g., 12g/m2 or less than 25 ppm,
etc (print)

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 Document Document Title: Effective Date: Revision No.&
Type: SHE 10/ 2024 Date
Form Investigation 10/ 2025
Form

Document No: Prepared BY: Approved By:

K OKE-SHEQ- SHEQ Manager CEO
006

DURATION OF POLLUTANT LESS THAN: 1 DAY 1 MONTH 1 YEAR 5 YEARS MORE THAN 5 YEARS
ON-SITE - CONTAINED ON-SITE - CONTAINED LOCAL REGIONAL
OTHER:
NATIONAL GLOBAL OFF-SITE AFFECTING ON-SITE

DESIGNATED INVESTIGATOR (TEAM) APPROPRIATE TO INVESTIGATE THE INCIDENT (qualifications, experience, expertise, etc.) NO
YES
INCIDENT INVESTIGATOR NAME: DATE OF INVESTIGATION:

F = Fatality MTC = Medical Treatment Case LTI = Lost Time Injury FAC = First Aid Case IDD = Irreversible Occupational
Diagnosed Disease RDD = Reversible Occupational Diagnosed Disease PD = Property Damage NIHL = Noise Induced Hearing Loss
MVA = Motor Vehicle Accident

5.0 Detailed Investigation Findings

5.1 Events leading to the incident

5.2 People Issues

5.3 The equipment

5.4 Environment

5.5 Post-incident management

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 Document Document Title: Effective Date: Revision No.&
Type: SHE 10/ 2024 Date
Form Investigation 10/ 2025
Form

Document No: Prepared BY: Approved By:

K OKE-SHEQ- SHEQ Manager CEO
006

COST/CAUSE ANALYSIS
SHE INCIDENT COSTS:
DESCRIPTION OF DIRECT AND INDIRECT COSTS COSTS

Investigation costs $

Medical costs $
Labour Replacement $
Productivity costs $
$
Property/asset damage/loss costs
Environmental costs $
Fire costs $
Total Incident Costs $
WHAT WAS THE DIRECT OR IMMEDIATE AND BASIC OR ROOT CAUSE OF THE
INCIDENT
DIRECT CAUSES/IMMEDIATE CAUSES (Tick in the box before the statement that correctly
describes the cause)
SUBSTANDARD PRACTICES/UNSAFE ACTS SUBSTANDARD CONDITIONS/UNSAFE CONDITIONS
OPERATING EQUIPMENT WITHOUT AUTHORITY INADEQUATE GUARDS OR BARRIERS
FAILURE TO WARN INADEQUATE PROTECTIVE/CONTROL EQUIPMENT
FAILURE TO SECURE OR CONTAIN IMPROPER PROTECTIVE/CONTROL EQUIPMENT
OPERATING IN IMPROPER MANNER e.g., SPEED DEFECTIVE TOOLS/ EQUIPMENT/MATERIALS
MAKING SAFETY OR CONTROL DEVICES INOPERABLE CONGESTION OR RESTRICTED MOVEMENT
REMOVING SAFETY OR CONTROL DEVICES INADEQUATE WARNING SYSTEMS
USING DEFECTIVE EQUIPMENT FIRE AND EXPLOSION HAZARDS
USING EQUIPMENT IMPROPERLY OR INCORRECTLY POOR HOUSEKEEPING/DISORDERLY WORKPLACE
FAILURE TO USE PPE HAZARDOUS ENVIRONMENT
IMPROPER LOADING NOISE EXPOSURE
IMPROPER PLACEMENT RADIATION EXPOSURES
IMPROPER LIFTING HIGH OR LOW TEMPERATURE EXPOSURES
IMPROPER POSITION FOR TASK HCS EXPOSURES (DUST, FUME, VAPOUR ETC.)
SERVICING EQUIPMENT IN OPERATION INADEQUATE OR EXCESSIVE ILLUMINATION
UNDER THE INFLUENCE OF ALCOHOL OR DRUGS INADEQUATE OR INAPROPRIATE VENTILATION
IMPROPER RESOURCE USE OR DISPOSAL INAPROPRIATE/UNSAFE DESIGN OR CONSTRUCTION
OTHER: OTHER:
BASIC CAUSES/ROOT CAUSES/INDIRECT CAUSES (Tick in the box before the statement that correctly describes the cause)

PERSONAL FACTORS JOB FACTORS

UNSUITABLE PHYSICAL/PHYSIOLOGICAL CAPABILITY INADEQUATE LEADERSHIP AND/OR SUPERVISION
UNSUITABLE MENTAL/PSYCHOLOGICAL CAPACITY INADEQUATE ENGINEERING OR PLANNING
PHYSICAL STRESS INADEQUATE PURCHASING
LACK OF KNOWLEDGE INADEQUATE MAINTENANCE
LACK OF SKILL INADEQUATE TOOLS AND EQUIPMENT
IMPROPER MOTIVATION INADEQUATE WORK STANDARDS/PROCEDURES
WEAR AND TEAR
ABUSE OR MISUSE
OTHER: OTHER:
PREVENTIVE ACTION – RECOMMENDED (Tick in the box before the statement that correctly describes the cause)

ADDRESSING PERSONAL FACTORS ADDRESSING JOB FACTORS

ATTEND TRAINING COURSE WRITE WORK STANDARDS (SPECIFICATIONS)
INSTRUCT HOW TO FOLLOW REVISED WORK STANDARD REVISE WORK STANDARDS (SPECIFICATIONS)

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 Document Document Title: Effective Date: Revision No.&
Type: SHE 10/ 2024 Date
Form Investigation 10/ 2025
Form

Document No: Prepared BY: Approved By:

K OKE-SHEQ- SHEQ Manager CEO
006

HAVE MEDICALLY EXAMINED REVISE RISK ASSESSMENT

TRANSFER TO ANOTHER JOB GUARD/PROVIDE PROTECTION
ENFORCE/WARN REPAIR
ATTEND SPECIFIC TRAINING (ON THE JOB) MODIFY
MENTOR LOCK-OUT
OTHER: HOUSEKEEPING
PROVIDE PROTECTION
OTHER:
INCIDENT DETAILS AND REMEDIAL ACTION PLAN
INCIDENT DESCRIPTION (PROVIDE A BRIEF DESCRIPTION OF THE INCIDENT AS SEEN BY THE INVESTIGATING TEAM)

SHE REPRESENTATIVE SIGNATURE: DATE:

INCIDENT CAUSE 1. Unsafe Acts OR Unsafe Conditions 2. Personal Factors OR Job Factors
1. Direct cause -

2. Basic cause -

3. Contributing Factors -

REMEDIAL/CORRECTIVE ACTION PLAN

ACCOUNTABILITY DATE COMP.

PERSON INVOLVED IN INCIDENT: PRINT NAME: SIGNATURE: DATE:

SHE DEPARTMENT: SHE COMMITTEE CHAIRPERSON: MANAGEMENT:

SIGNATURE: SIGNATURE: SIGNATURE:
PRINT NAME: PRINT NAME: PRINT NAME:
DATE: DATE: DATE:

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 Document Document Title: Effective Date: Revision No.&
Type: SHE 10/ 2024 Date
Form Investigation 10/ 2025
Form

Document No: Prepared BY: Approved By:

K OKE-SHEQ- SHEQ Manager CEO
006

Head of Department (HOD) Incident Comments

Risk Assessment of Implemented Corrected Action

The above action was implemented and is effective Yes No Proof of action attached Yes No

NOTES:

Is there any possible new/additional risk in terms of: SAFETY HEALTH ENVIRONMENT YES NO UNCERTAIN
Indicate the additional hazards/risks and specify the action to be taken ACTION BY DATE

INCIDENT ASSESSOR: PRINT NAME: SIGNATURE:

DATE:

ATTACH ALL RELEVANT DOCUMENTS PERTAINING TO THIS INVESTIGATION

TO THIS PAGE (E.G. STATEMENTS, PHOTOGRAPHS, QUOTATIONS, CLAIM,
DOCUMENTATION ETC.)

INCIDENT INVESTIGATION GUIDELINES

1. Record the incident in the appropriate register (SHE incident register).

2. Always visit the scene of the incident – if possible.

3. Firstly, identify the direct or immediate cause of the incident.

a. Substandard practice/unsafe act/unsafe behaviour.
b. Substandard condition/unsafe condition /unsafe environment.

4. Secondly identify the basic or root cause of the incident.

a. Personal or job factor involved.
b. Job factor/environment factor.

5. Determine the corrective action necessary to address the basic cause (personal or job factor) of the
incident.
6. The corrective action must always be quantifiable.

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 Document Document Title: Effective Date: Revision No.&
Type: SHE 10/ 2024 Date
Form Investigation 10/ 2025
Form

Document No: Prepared BY: Approved By:

K OKE-SHEQ- SHEQ Manager CEO
006

7. Avoid non-quantifiable corrective action recommendations such as “be more careful, work slower,
pay more attention” –it means nothing.
8. Always ensure that proof of the action that was taken to prevent a similar incident from occurring
again, is kept with the investigation records.
9. Ensure that all the necessary role players sign the investigation record before it is archived.

10. When filling in the form, tick in the box before or after the statement or word that most correctly describes the
scenario. Where further descriptions are needed, print in the space provided.