METTKO Incident Management

A – To Be Completed By The Initiator

Date	Initiator	CAR Number
Source of Corrective Action Request Customer Supplier Product Process EA Finding IA Finding
Requirement Reference
Description of the Deficiency

B – To Be Completed By The Investigator

1. Interim Correction / Containment Actions

2. Analysis of Causes

Why 1?	Why 2?
Why 3?	Why 4?
Why 5?

3. Proposed Actions to Address the Root Cause(s)

Action 1	Due
Action 2	Due
Action 3	Due
Avtion 4	Due
Action 5	Due
Action 6	Due

C – To Be Completed By The Reviewer / Approver

Review Risk Assessment

Review Similar Processes

Review Similar Products

Approver Initials

D – To Be Completed By The Implementer

Evidence attached showing actions were implemented as approved (YES)
Evidence attached showing implemented actions were effective (YES)

E – To Be Completed By The Verifier

Were actions implemented as planned and on-time?	Comments
Validation of effectiveness (deficiency resolved permanently?)	Comments
CAR Closed By (print name)	Date
Escalation Control (Second Stage CAR#)	Issued To

A – To Be Completed By The Initiator

Date	Initiator	NCR #
Type of Non-Conformance Customer Supplier Product Service Process Quality
Investigator
Description of Non-Conformance
Expected Response Date	Investigator's Signature

B – To Be Completed By The Investigator

1. Immediate Containment Action / Disposition	Date for Completion
Disposition Reject / Scrap Accept with Concession Re-Grade Rework Repair with Concession Other (specify)
Concession by: Internal or Customer	Approved By
2. Action Plan To Correct Non-Conformance (Rework / Repair Instructions)
Investigator's Signature	Date
Date for Completion

C – To Be Completed By The Verifier

NCR Closed By (print name)

Date

CAPA# (if required)

A – Project Definition / Clarification

Project Name	Customer
Team Members
Start Date	Project Leader
Sponsor
Project Definition / Clarification (PFDs, Cause and Effect diagrams)
Target Date for Closure	Project Leader's Signature

B – Process Analysis

Process Flow Diagrams, Cause and Effect Diagrams, Process Measures (show supporting analysis and data, attach documents as needed)

C – Data Analysis

Most Probable Causes

Real Causes

D – Solution Action Plan

Action	Timing	Resp.	% Complete	Comments

E – Validation of Project Effectiveness and Closure

Did the CI project achieve an effective and sustainable solution?	What were the results? (attach evidence if appropriate)
Validated By (print name)	Date
CI Project Closed By (print name / title)	Date

This report is to be completed as soon as practical or within 24 hours after the incident. Complete this report if First Aid or Medical Aid has been provided or is required. If First Aid is required, also fill in the First Aid Log Book found in the first aid kit. If Medical Aid (any treatment other than first aid) has been provided or is required, complete and submit WSIB Form 7.

Identifying Details – Employer

Employer	Address
Supervisor	City
Telephone	Province
Fax	Postal Code

Identifying Details – Injured Employee

Name	Address
Age	City
Telephone	Province
Fax	Postal Code
Occupation	Experience at Work Involved
Nature of Injury (including if First Aid / Medical Treatment / Restricted or modified duty / or occupational illness; including body part affected & type of injury)

Witnesses

Witness (A)

Name	Address
Employer	City
Occupation	Province
Telephone	Postal Code

Witness (B)

Name	Address
Employer	City
Occupation	Province
Telephone	Postal Code

Witness (C)

Name	Address
Employer	City
Occupation	Province
Telephone	Postal Code

Accident Injury Care

a. First Aider	b. Doctor
Address	Address
City	City
Province	Province
Postal Code	Postal Code
Telephone	Telephone
c. Clinic	d. Hospital
Address	Address
City	City
Province	Province
Postal Code	Postal Code
Telephone	Telephone
e. Treatment and Care Provided

Reporting

Accident Date	Accident Time
Project	Location of Accident
Address	City, Province

Reported to Supervisor

Name	Telephone
Date	Time
Notes

Reported to Ministry of Labour (if Critical)

Name	Telephone
Date	Time
Notes

Reported to Head Office

Name	Telephone
Date	Time
Notes

Accident Report Part B: Accident Description

Explain what happened (what, where, when, who, how, weather, housekeeping, tools involved)
Sketch / Diagram (describe)
Immediate Cause
Underlying Cause
How can the accident be prevented from happening again?
Actions taken to prevent recurrence
Action / Due By	Report By

Signatures

Employee Signature	Date
Management Signature	Date

A Near Miss Event is one that had a likelihood of resulting in injury, property damage, or affecting the project's development, but did not because of luck or some other intervening factor. Near misses give us a second chance to correct dangerous or risky behaviors or conditions before they result in future injury, property damage, re-work, or delays.

Near Miss Details

Project	Near Miss Related To Health & Safety Quality
Description of Near-Miss
Precise Location
Person to Whom Near-Miss Has Been Reported
Date of Report	Time
Name of Person Reporting

Corrective Action

Corrective Action – Near-Miss Reported	Person Responsible	Status

Date of Corrective Action

Time