Title Page
-
This Form is to be completed for all Accidents, Incidents or Events where an Injury, Damage, Harm to the Environment or a Near Miss, has occurred. The Investigation should be completed by the Line Manager or Person Responsible for either the Injured Party or the location of the incident. Where this Accident/Incident involves a person and personal injury selected the form will expand to include further questions, add the details from the report or LTi item in Safety Culture. (Additional guidance is available to view in the attached document and in the Investigation Report section).
-
Linked to Issue Number IS-...
-
Title of the Accident or Incident or Event
-
Date and time of the event
-
Site conducted
-
Date Investigation Conducted
-
Name of the person(s) involved in the Accident, Incident or Near Miss?
-
Investigation completed by?
-
Does this Accident or Incident constitute a RIDDOR or Schedule 5?
- RIDDOR Notifiable
- Schedule 5
- Not Notifiable
Event Details
-
Name of the person(s) involved in the Accident, Incident or Near Miss?
-
Is the person or parties involved in the incident one of the following?
- Member of the Public
- Employee
- Visitor
- Contractor
- No person involved
-
Mark the Exact Location of where the event occurred?
-
Attach any additional information, statements, photos, authority reports to this form. (Documents must be pdf format)
-
Type of Incident
- Personal injury
- Unsafe Act
- Unsafe Condition or Safety System compromised
- Damaged Asset, Equipment or Structure
- Moving Vehicle involved
- Environmental Impact or Harm
-
What injuries were sustained?
-
Was first aid or medical treatment administered at the time of the incident?
-
State what treatment was provided?
-
Enter the name and contact details of the person or First Aider who provided initial first aid.
-
Has this incident been recorded as an LTi (Lost Time Injury) in Safety Culture?
-
State the reason why it has become an LTi.
-
Did the Injured Party (IP) attend Hospital or Medical Centre?
- Attended on advise of ABSL employee
- Attended on advise/taken by EMS
- Attended of own accord later on
- Refused to attend
- Did not attend
-
Address of the Hospital or Medical Centre.
-
Date/Time attended
-
Have the witnesses provided statements? (N/A if no witnesses)
-
Ensure that all witness statements are taken and uploaded onto this form
-
Attach any photos of location, injuries or damage.
-
Is CCTV footage available?
-
Provide details of immediate actions taken at the time of the Accident/ Incident/ Event required to prevent re-occurrence.
Root Cause Identification - 5 WHY's.
-
Identify all the specific things that happened and find their root cause by using the 5 "WHY's" (also refer to the guidance for consideration in the attached document).
-
Follow the principles of the RCA - Root Cause Analysis model and ask the question WHY is that ? do this by clicking on the green "+" to repeat each section until you have satisfied you have gathered enough information to understand the Root Cause(s) to complete the ‘Investigation Conclusion’ section.
What Happened?
-
Describe what happened.
WHY is that?
-
Why?
-
What was the Root Cause?
Investigation Conclusion
-
Have the Root causes been identified?
-
Conclusion of the investigation
-
Signed by Investigator
Senior Manager Approval
-
THIS FORM MUST BE KEPT IN A SECURE LOCATION
TO COMPLY WITH DATA PROTECTION LEGISLATION. -
Has this investigation been conducted fully and in line with ABSL Procedures?
-
Have all actions identified in this investigation been completed?
-
Approving Manager
-
Date
