005 TW Accident/Incident Investigation

• Service strike incestigation

• Document No.

• Conducted on

  Date

• Prepared by

Incident details

• Date and time of incident;

  Date

• Type of Incident

  Accident

  Near Miss

  Dangerous occurrence

• Name of Principal Contractor

  David Wilson

  Barratt

  Redrow

  Persimmon

  TW Civils

• Site Address that the incident took place.

• Detailed description of location of incident (please be specific, plot numbers, etc).

• Photos of various aspects of the location of the incident. Do not approach any damaged service in such a way that you may sustain Injury doing so.

  Media

• Weather conditions.

  Select Clear Overcast Fog Snow Rain High Winds Extremely warm day Extremely cold day Dark (Low visibility) Below 0 degrees Celcius

  • Clear
  • Overcast
  • Fog
  • Snow
  • Rain
  • High Winds
  • Extremely warm day
  • Extremely cold day
  • Dark (Low visibility)
  • Below 0 degrees Celcius

Personnel

• Supervisor

  Sign

• First Aider

  Sign

First Aid

• Was first aid administered?

  Yes

  No

• Detail what first aid was administered

• Where the emergency services called?

  Yes

  No

• Was the individual taken to hospital?

  Yes

  No

• What information do you have at current time?

Plant/Equipment involved

• Was plant/equipment involved in this incident?

  Yes

  No

• Has all plant received weekly inspections?

  Yes

  No

• Do all operatives involved have relevant qualifications to operate plant?

  Yes

  No

Who has been contacted, by who, and when?

• Principle Contractor

  Yes

  No

  N/A

• Internal TW H&S

  Yes

  No

  N/A

• Next of Kin

  Yes

  No

  N/A

• HSE Informed?

  Yes

  No

  N/A

Witness statements

• Witnesses 1

  Media

• Name and signature of the witness 1

  Sign

• Witnesses 2

  Media

• Name and signature of the witness 2

  Sign

• Witnesses 3

  Media

• Name and signature of the witness 3

  Sign

Training Qualifications & Experience

• Do all people involved hold relevant training cards/qualifications?

  Yes

  No

• What training qualifications do relevant people have

Action: Short Term

• Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following correct safety procedures and instructions)

• What was the immediate action taken to correct the issue (how was this done):

• Who was the responsible party for correcting the issue:

Moving forwards

• Lessons Learned:

• What is the long term action needed to correct the issue:

Investigation Conclusions

• Where does the fault fall, and why did this happen?

Person Completing Form (please sign below)

• The above report a true reflection of the Incident to the best of my knowledge.

  Sign