Accident/incident Report From 2.8B

• Is the incident currently reportable under RIDDOR

  Yes

  No

• Is the incident associated with a loss time injury (LTI)

  Yes

  No

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• undefined

Description of incident - describe in detail

• undefined

Statement of operative

• I understand that by signing this statement it can be referred to as a statement of truth related to the events leading up to & including the accident/incident

• Has the individual provided a written statement - if so upload and attach to this document.

  Yes

  No

  N/A

• Add signature

  Sign

• Date of Statement

  Date

Witness Statement

• Was the accident witnessed

  Yes

  No

• list all relevant witnesses and attach copies of their signed statements

• To be completed by the investigation team as detailed below

• Add signature

  Sign

• Add signature

  Sign

• Add signature

  Sign

• Date of Investigation

  Date

Investigation Notes

• undefined

Immediate Cause

• Describe in as much detail as appropriate.

Root Cause

• Define the root cause in as much detail as appropriate

• Are risk assessments and safe working practices associated with this incident up to date

  Select

Corrective & Preventative Action (CAPA)

• Detail all corrective and preventative actions implemented associated with this accident. Ensure all actions are captured when updating the risk assessment/safe working practices.

• undefined

• In all case of damage or Injury, has the financial controller been informed for insurance purposes?

  Yes

  No

  N/A

Investigation Sign off

• Investigation Team

  Sign

• Investigation Team

  Sign

• Investigation Team

  Sign

• Operations Manager ( Quarries only)

  Sign

• Managing Director

  Sign