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Incident Investigation & Root Cause Form

Look beyond a single operator error to work design, equipment, training, supervision and site conditions. Check whether corrective actions actually reduce the risk.

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How to use this worksheet

Arrange emergency care, make the area safe, control continuing hazards and meet applicable notification duties.
Establish a factual timeline; distinguish witness accounts from physical evidence.
Separate immediate event factors from the underlying system weaknesses that allowed them.
Assign dated corrective actions, prioritising stronger hazard controls wherever feasible.
Recheck the worksite, communicate lessons and monitor whether the risk remains controlled.

Worked field example

Worked example — A worker trips over a temporary power cable. Immediate factor: Cable across a walkway. Underlying causes: No routing plan, physical protection or inspection ownership. Stronger action: Segregated cable routing and verified recurring site checks.

SERNEM — FIELD WORKSHEET

Incident Investigation & Root Cause Form

Adapt this worksheet to actual site conditions.

Initial record

Incident date / timeSite / locationActivity and affected work groupInvestigation teamEmergency response / required notifications

Corrective action and verification log

Action linked to root cause	Owner	Due date	Evidence / effectiveness
Action linked to root cause 1	Owner 1	Due date 1	Evidence / effectiveness 1
Action linked to root cause 2	Owner 2	Due date 2	Evidence / effectiveness 2
Action linked to root cause 3	Owner 3	Due date 3	Evidence / effectiveness 3
Action linked to root cause 4	Owner 4	Due date 4	Evidence / effectiveness 4

Evidence and causal analysis

Timeline before, during and afterPhysical evidence and statement sourcesImmediate event factorsUnderlying system / organisational causesWhich controls existed, were absent or failed?

Close-out

Lessons communicated / affected groupsWho verified effectiveness, when and how?

People's safety, emergency care and required legal notifications come first. This general worksheet does not replace statutory reporting, formal investigations or competent specialist review.

Frequently asked questions

How does a root cause differ from an immediate factor?

An immediate factor is a condition directly involved in the event. An underlying cause explains why the system permitted that condition to exist.

When should an action be considered closed?

Completion alone is insufficient. An accountable person should verify implementation and that the selected control works effectively.

Related SERNEM resources

Incident reporting guide →Near miss guide →TRIR calculator →

Technical sources

People's safety, emergency care and required legal notifications come first. This general worksheet does not replace statutory reporting, formal investigations or competent specialist review.