Incident Report Form - Department of Physics - Ryerson University
Incident Report Form - Department of Physics - Ryerson University
Incident Report Form - Department of Physics - Ryerson University
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<strong>Ryerson</strong> <strong>University</strong> - CEHSM AIE Internal <strong>Report</strong> Page 4 <strong>of</strong> 4IMMEDIATE CAUSES: CHECK ALL APPLICABLESUBSTANDARD ACTS/PRACTICESAn Unsafe Act or Practice is a violation <strong>of</strong>a known or accepted safe procedure whichcould permit the occurrence <strong>of</strong> an accident.SUBSTANDARD CONDITIONSAn Unsafe Condition is a hazardous physicalcondition or circumstance which could directlypermit the occurrence <strong>of</strong> an accident.Operating equipment without authority Inadequate guards or barriersFailure to warn Inadequate or improper protective equipmentFailure to secure Defective tools, equipment or materialsOperating at improper speed Congestion or restricted actionFailure to follow procedures Inadequate warning systemRemoving or making safety devices inoperable Fire and explosion hazardsUsing defective equipment Poor housekeeping; disorderUsing equipment improperly Hazardous environmental conditions; gases, dusts, smokes, fumes, vapoursFailing to use personal protective equipment properly Noise exposuresImproper loading Radiation exposuresImproper placement Temperature Extremes (High or low temperature exposures)Improper lifting Inadequate or excess illuminationImproper position for task Inadequate ventilationServicing equipment in operationHorseplayUnder the influence <strong>of</strong> alcohol and/or other drugsBASIC CAUSES: CHECK ALL APPLICABLEPERSONAL FACTORSJOB/SYSTEM FACTORSInadequate Physical/Physiological Capability (Doctor's Opinion) Inadequate leadership and/or supervisionInadequate Mental/Psychological Capability (Doctor's Opinion) Inadequate engineeringPhysical or Physiological Stress Inadequate purchasingMental or Physiological Stress Inadequate maintenanceLack <strong>of</strong> Knowledge Inadequate tools/equipmentLack <strong>of</strong> Skill Inadequate work standardsImproper Motivation Excessive Wear and tearAbuse or misuseREVIEWER'S REACTIONS TO THE INVESTIGATOR'S ANALYSIS OF THE BASIC CAUSESOF THIS ACCIDENT AND THE REMEDIAL ACTIONS DIRECTED AT POSSIBLEINADEQUACIES IN THE SYSTEM, ITS STANDARDS OR COMPLIANCE TO THE STANDARDS.Note: In most cases the Reviewer should be at the level <strong>of</strong> aPrincipal Investigator / Coordinator / Manager / Chair / Director / Dean.Note: The Investigator will be the Supervisor <strong>of</strong> the person who was involved in the accident/incidentName <strong>of</strong> Reviewer / Signature / Title / DateCentre for EHS ManagementFile: UEHS_FM_001_2008.xls
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