Accident and Incident Investigation

Toray Resin Company Accident and Incident Investigation

Investigation Details

• Who will be leading this investigation?

• Will anyone be assisting in the investigation?

  Yes

  No

• Please enter the date of this investigation.

  Date

• What kind of incident are you investigating?

  Select Lost time OSHA Recordable Near Miss First aid (Toray) First aid (Clinic)

  • Lost time
  • OSHA Recordable
  • Near Miss
  • First aid (Toray)
  • First aid (Clinic)

Incident Details

• When did the incident occur?

  Date

• Name of injured person (if any)

• Age & Sex of injured

• Service date of injured

  Date

• What type of person was injured? (if any)

  Contractor

  Visitor

  TREC employee

• Which part of the body was injured? (if any)

  Select Head Face Eyes Neck Shoulders Arms Hands Fingers Chest Stomach Upper leg Lower leg Foot Toes

  • Head
  • Face
  • Eyes
  • Neck
  • Shoulders
  • Arms
  • Hands
  • Fingers
  • Chest
  • Stomach
  • Upper leg
  • Lower leg
  • Foot
  • Toes

• Location of incident

• Supervisor of the injured

• Give details of any tasks being carried out at the time of the incident/injury?

• Have all persons involved in the incident received information, instruction and training for the tasks relating to the incident?

• Describe in detail what happened?

• Describe in detail any injury sustained, if no injury, describe any damaged equipment, plant or machinery etc

• Please add as many images as you can that relate to the incident.

  Media

• List all witnesses of the incident

Medical Treatment

• Was First Aid administered on-site

  Yes

  No

  N/A

• Describe what assistance was provided by the First Aider, list any medical equipment used (bandage, eyewash etc.)

• Did they require any further treatment?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• What was the outcome of this?

• Please provide dates and times

  Date

Witness Statement

• Please interview all witnesses

• Name(s) & Statement(s)

• Please provide dates and times

  Date

How did the incident/injury occur?

• Please list the main cause or causes of this incident or injury

  Select Rushing Frustration Fatigue Complacency

  • Rushing
  • Frustration
  • Fatigue
  • Complacency

• Please list any contributing factor or factors relating to this incident or injury

  Select Eyes not on task Mind not on task Line of fire Balance, traction or grip

  • Eyes not on task
  • Mind not on task
  • Line of fire
  • Balance, traction or grip

• Describe in detail your findings as to how the incident has occurred?

Corrective and Preventive Action

• What corrective actions have been taken immediately?

• Describe what actions can be taken to prevent a recurrence of this incident (Improved training, PPE, improved housekeeping, improved maintenance etc)

Incident Reporting

• Is this incident reportable under OSHA

  Yes

  No

  N/A

• Did the injured person require time off work

  Yes

  No

  N/A

Results of Investigation

• Explain the results of your findings, take into account all factors and provide a balanced view, if there is a clear cause for the incident, be sure to list it.

• If any equipment, plant, machinery have been damaged please list and describe the issues

Authorisation

• I agree that all information provided by this investigation is accurate.

• Signed by injured person

  Sign

• Signed by Lead Investigator

  Sign