Title Page
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Site conducted
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Conducted on
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Prepared by
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Name of person involved the accident/incident:
Investigation form
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Attach any additional information, statements, photos, authority reports to this form.
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Are they
- Employee
- Visitor
- Contractor
- No person involved
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Exact location of the accident/incident:
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Manager/supervisor of the area where the accident/incident happened
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Date of accident/incident
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Time of accident/incident (24hrs clock)
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Did the accident/incident require reporting to authorities? (include emergency services & enforcing authorities)
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How and when the accident/incident was reported to the authorities? (HSE, other governing bodies)
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Have the witnesses provided statements?
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Ensure that all witness statements are taken and uploaded onto this form
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Were there any photos taken?
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Ensure that photos are uploaded onto this form
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Is CCTV footage available?
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Details of the accident/incident (what happened?)
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Were there any injuries sustained?
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Location of injury: (write as many details as possible)
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First aid treatment administered
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Name of first aider:
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Did the injured person loose consciousness?
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Was the injured party admitted to the hospital?
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Did the injured party refused to go to the hospital?
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Is the injury likely to cause a loss of working time?
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Was the person authorised in the area?
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How much experience the person involved has on the activity?
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Does the person appear to have acted in an unsafe manner?
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List all risk assessments undertaken for the activity involved in the accident/incident
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How the findings of the risk assessment had been communicated to the workforce?
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Was there a safe procedure in place? (Safe Working Procedure)
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Was the procedure followed prior to the accident/incident?
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Were there any environmental conditions that may have had a bearing on the accident/incident?
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Were there any safety devices required, were they available and in use?
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Please describe safety devices required.
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Was any equipment or machinery involved?
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(details of equipment, serial number, part of machinery, any fault on them)
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Were any hazardous substances involved in the accident/incident?
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Describe the supervision in place at the time of the accident/incident:
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Was the person involved trained in regard to the activity?
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Have all the risk assessments associated with the accident/incident been reviewed?
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Explain any remedial action taken or required to prevent re-occurrence
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Have the actions identified been implemented?
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Type of Incident
- Safety System compromised
- Unsafe Act
- Equipment/asset damage
- Vehicle involvement
- Environmental
- Personal injury
Accident/incident investigation conclusion
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General causes:
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Management causes:
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Technical causes:
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Immediate causes:
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Underlying causes:
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Root causes:
Sign off
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THIS FORM MUST BE KEPT IN A SECURE LOCATION
TO COMPLY WITH DATA PROTECTION LEGISLATION. -
Name of person carrying out the investigation
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Date
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Name of Senior manager
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Date
