Accident Investigation Reports Copy

• Document No.

• Watson Electric Report

  Select Automobile Accident Burn Cut Line Exposure Heat Stroke Heat Exhaustion Heart Attack Lifting Back Injury incident Repetitive trauma incident Slips and Falls

  • Automobile Accident
  • Burn
  • Cut Line
  • Exposure
  • Heat Stroke
  • Heat Exhaustion
  • Heart Attack
  • Lifting Back Injury incident
  • Repetitive trauma incident
  • Slips and Falls

• Conducted on

  Date

• Prepared by

• Accident Date / Time

  Date

• Division:

• Date report complete

  Date

• Employee name

• Employee identification number:

• Job Title

• Supervisor

• Employee home address

• Employee cell/home phone

• If auto accident:

  yes

  no

• Watson Electric drivers description of accident:

• Immediate drug screen performed

  yes

  no

Automobile/Equipment Accident

• Auto/Equipment accident:

  yes

  no

• Location of accident: street, city, state

• Intersection if applicable:

• Type of collision:

  Other

• Photographs from accident scene:

• Measurement of skid marks:

• Skid marks made from other parties involved in accident:

  yes

  no

• Model and make of Watson Electric vehicle: No., year, make, model

• Model and make of other vehicles: year, make, model

• Weather factors:

  Select n/a sun rain snow ice sleet wind

  • n/a
  • sun
  • rain
  • snow
  • ice
  • sleet
  • wind

• Which driver was effected by the weather:

  Select Watson Electric Other Party

  • Watson Electric
  • Other Party

• Comments:

Injuries

• Did injuries occur:

  yes

  no

• Names and phone numbers of those injuries:

• Were persons injured transported to a medical facility:

  yes

  no

• Mode of transportation:

  Select EMS Employer Other

  • EMS
  • Employer
  • Other

• Name of medical facility, address, state and phone number:

Eye witness information:

• Name address phone cell/home

• Eye witness description and diagram of accident:

• Add media

  Media

• Supervisors description and diagram of accident with any unusual findings: illegal substances, no drivers license with driver or attach photo.

• Add media

  Media

• Recommendations on correct action to prevent similar accidents:

• Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

• Supervisors signature:

  Sign

Burn Incident Report

• Burn incident report

  yes

  no

• Date and time of Burn incident

  Date

• Type of Burn:

  Select Other Arc flash Electrical shock Hot surfaces

  • Other
  • Arc flash
  • Electrical shock
  • Hot surfaces

• Location of incident: job site, street, town, state

• What type of electrical device caused the Burn:

• Voltage was tested by:

• What procedures were used to test the voltage?

• Indicate measurement of voltage:

• Rubber gloves worn by employee:

  yes

  no

• Glove test date:

  Date

• List protective gear worn by employee:

• We're rubber blankets used:

  yes

  no

• Rubber blanket test date:

  Date

• We're there burn marks on the employees clothing:

  yes

  no

• Was employee knocked away from or remained connected to electrical force:

  yes

  no

• Photographs of area where incident occurred:

  yes

  no

• Photo

  Media

• NOTE: ANY TOOL BEING USED NEEDS TO BE TURNED INTO THE SAFETY REPRESENTATIVE

Injuries

• Did injuries occur?

  yes

  no

• Did employee lose consciousness?

  yes

  no

• Names and phone numbers of other injured in the accident:

• Were persons injured transported to a medical facility:

  yes

  no

• Mode of transportation:

  EMS

  Employer

  Other

• Name of Medical Facility, address, state, phone:

Eye witness information:

• Name address, phone cell/home

• Eyewitness description of accident or attached photo:

• Photo

  Media

• Supervisor description and diagram of Burn incident and unusual findings or attach photo:

• Photo

  Media

• Recommendations on corrective actions to prevent similar accidents:

• Safety representative shall provide transportation for employee to drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours)

• Supervisor Signature

  Sign

• Yes

  No

  N/A

• Date and time of Burn incident

  Date

• Type of Burn:

  Select Other Arc flash Electrical shock Hot surfaces

  • Other
  • Arc flash
  • Electrical shock
  • Hot surfaces

• Location of incident: job site, street, town, state

• What type of electrical device caused the Burn:

• Voltage was tested by:

• What procedures were used to test the voltage?

• Indicate measurement of voltage:

• Rubber gloves worn by employee:

  yes

  no

• Glove test date:

  Date

• List protective gear worn by employee:

• We're rubber blankets used:

  yes

  no

• Rubber blanket test date:

  Date

• We're there burn marks on the employees clothing:

  yes

  no

• Was employee knocked away from or remained connected to electrical force:

  yes

  no

• Photographs of area where incident occurred:

  yes

  no

• Photo

  Media

• NOTE: ANY TOOL BEING USED NEEDS TO BE TURNED INTO THE SAFETY REPRESENTATIVE

Injuries

• Did injuries occur?

  yes

  no

• Did employee lose consciousness?

  yes

  no

• Names and phone numbers of other injured in the accident:

• Were persons injured transported to a medical facility:

  yes

  no

• Mode of transportation:

  EMS

  Employer

  Other

• Name of Medical Facility, address, state, phone:

Eye witness information:

• Name address, phone cell/home

• Eyewitness description of accident or attached photo:

• Photo

  Media

• Supervisor description and diagram of Burn incident and unusual findings or attach photo:

• Photo

  Media

• Recommendations on corrective actions to prevent similar accidents:

• Safety representative shall provide transportation for employee to drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours)

• Supervisor Signature

  Sign

Cut Line Incident

• Cut line incident

  yes

  no

• Date / Time line was cut:

  Date

• Type of line cut:

• Location of cut line street, town, state

• Intersection if applicable:

• Was cut line active:

  yes

  no

• Was the cut line located in DOT right of way:

  yes

  no

• Photograph of cut line measured to locate mark with tape measure readable?

  yes

  no

• Photo

  Media

Locate information

• Locate ticket number:

• Name of person who called for the locate ticket:

• Was update required for locate ticket?

  yes

  no

• Date of up dated locate ticket:

  Date

• Name and phone number of persons updating the locate ticket:

Other Companies involved in project:

• Name, address, city, state, phone number:

Injuries

• Did injuries occur?

  yes

  no

• Names and phone numbers of those injured in the accident:

• Were injured people transported to a medical facility:

  yes

  no

• Mode of transportation:

  EMS

  Employer

  Other

• Name of Medical Facility, address, city, state, phone number:

Eye witness information:

• Name, address, phone cell/home:

• Eye witness description of accident or attached photo:

• Photo

  Media

• Supervisors description and diagram of cut line with unusual findings or attach photo. Show all marks with color description on diagram and note the date and time diagram was made.

• Photo

  Media

• Recommends on corrective action to prevent similar accidents:

• Safety representatives shall provide transportation for the employee to drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours.

• Supervisors signature:

  Sign

Exposure Incident

• Exposure incident

  yes

  no

• Date / Time of exposure:

  Date

• Location of where exposure occurred: Street, Town, State

• Were MSDS sheets available:

  yes

  no

• Type of Exposure / Material:

  Select Asbestos Silica Lead Arsenic Contaimination Other

  • Asbestos
  • Silica
  • Lead
  • Arsenic Contaimination
  • Other

• Other type of exposure:

• Was area contaminated and / or isolated:

  yes

  no

• HAZMAT crew called:

  yes

  no

• Photographs of exposure area and materials (attached)

  yes

  no

• Photo

  Media

• Now long was employee exposed to hazardous material:

• Did employee complain of any symptoms prior to exposure:

  yes

  no

• Describe in detail the employee's symptoms after exposure:

• Has the employee had a history of similar symptoms / complaints:

  yes

  no

• Were there others working in the exposed area:

  yes

  no

• List names of others working in the exposed area:

• Were environmental studies made available prior to beginning work:

  yes

  no

• Describe in detail what was being done at the time of exposure:

• Was information made available covering affects of exposure:

  yes

  no

• If yes describe:

Injuries

• Did injuries occur:

  yes

  no

• Were persons injured transported to medical facility?

  yes

  no

• Mode of transportation:

  EMS

  Employer

  Other

• Name of Medical Facility, address, city, state, phone number:

Eye witness information:

• Name, address, phone cell/home

• Eye witness description of accident or attached photo:

• Photo

  Media

• Supervisors description of exposure and any unusual findings or attached photo:

• Photo

  Media

• Recommendations on corrective action to prevent similar accidents:

• Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident drug and alcohol testing must be done within 2 hours).

• Supervisors signature :

  Sign

Heat Stroke, Heat Exhaustion, Heart Attack

• Heat Stoke, Heat Exhaustion, Heart Attack

  yes

  no

• Location of incident: Street, Town, State

• Time employee arrived at work:

  Date

• Time of event:

  Date

• Signs / Symptoms of event:

  Select chest pain nausea vomiting fatigue shortness of breath weakness headache dizziness fainting heavy sweating paleness muscle cramps

  • chest pain
  • nausea
  • vomiting
  • fatigue
  • shortness of breath
  • weakness
  • headache
  • dizziness
  • fainting
  • heavy sweating
  • paleness
  • muscle cramps

• Medical history of heart disease or stroke:

  yes

  no

• Weather factors:

  Select n/a sun rain snow ice sleet wind

  • n/a
  • sun
  • rain
  • snow
  • ice
  • sleet
  • wind

• Temperature:

• Specific description and diagram (attached photo)

• Photo

  Media

Injuries

• Did injury occur:

  yes

  no

• Were persons injured transported to a medical facility?

  yes

  no

• Mode of transportation:

  Select EMS Employer Other

  • EMS
  • Employer
  • Other

• Name address of medical facility:

Eye witness information:

• Name, Address, phone cell/home:

• Eye witness description of incident or attached photo:

• Photo:

  Media

Supervisors description of accident:

• What was the employee doing within 2 hours prior to the medical event occurred:

• What type of work / activities was employee doing at the time of the medical event:

• Did employee take any leave prior to the medical event:

  yes

  no

• Could a specific event in the course of employment been the cause of the medical event:

  yes

  no

• If, yes describe:

• We're there any complaints by the employee prior to the medical event:

  yes

  no

• Describe:

• Any personnel issues employee was talking about prior to the medical event:

  yes

  no

• If yes, describe in detail:

• Recommendations on corrective action to prevent similar accident:

• Safety representative shall provide transportation for the employee to a drug testing facility. (if this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

• Supervisors signature

  Sign

Lifting/Back injury

• Lifting/back injury

  yes

  no

• Date / Time of incident:

  Date

• Location: job site, City, State

• Specific cause of injury:

• Specific location on back where injury occurred:

• Chief complaint of pain:

• Repetitive activity:

  yes

  no

• Treatment:

  Select none first aid only Urgent care hospital

  • none
  • first aid only
  • Urgent care
  • hospital

• Treating hospital, address of treating facility, physicians name, phone number:

Incident report:

• Photographs:

  yes

  no

• Select scene employee injury shoes cause of injury (object/area)

  • scene
  • employee injury
  • shoes
  • cause of injury (object/area)

• Add media

  Media

• Description of scene:

• Description of working being performed at time of incident:

• Complain from employee before accident/incident:

• Complain from employee after accident/incident:

• Conditions of floor or stairs, if applicable:

• Description of what employee was lifting:

• Inspection and type of shoes employee was wearing:

• Has employee requested time off before this alleged accident:

  yes

  no

• Was ergonomics applied to the job specifics for this employee:

  yes

  no

• Weather factors: (if outdoors)

  Select N/A sunny rain snow ice sleet wind

  • N/A
  • sunny
  • rain
  • snow
  • ice
  • sleet
  • wind

• Other factors:

  Select loose sand unlevel terrain hole condesation

  • loose sand
  • unlevel terrain
  • hole
  • condesation

Eye witness information:

• Name, address, phone cell/home:

• Eye witness description of incident and diagram or attached photo:

• Add media

  Media

• Supervisors description of accident/incident and diagram or attached photo:

• Add media

  Media

• Recommendations: Supervisor

• Recommendations: employee

• Recommendations: equipment

• Recommendations: environment

• Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).

• Supervisors signature:

  Sign

Repetitive Trauma

• Repetitive Trauma

  yes

  no

• Date/Time of incident:

  Date

• Location where incident occurred: Job site, Address, State

• Intersection if applicable:

• Describe the history of exposure to hazardous activity (business and pleasure):

• Was an ergonomic assessment performed on the work area prior to the incident:

  yes

  no

• Describe full and complete job description:

• Had employee requested leave prior to the incident:

  yes

  no

• List any known hobbies of employee:

• Describe the employees daily routine of job, including but not limited to breaks and lunch:

• Photographs of incident and injury:

  yes

  no

• Photo

  Media

• Did employee complain of any symptoms prior to accident:

  yes

  no

• Describe in detail the employee's symptoms after incident:

• When did employee begin to complain of symptoms:

• Has the employee had a history of similar symptoms/complaints:

  yes

  no

• Does the employee have any other health issues:

  yes

  no

• What are these issues:

• Does the employee follow the safety policies at all times:

  yes

  no

• Explain concerns:

• Has the employee ever been written up for violations of the safety policy:

  yes

  no

• Were there other employees working in the area:

  yes

  no

• List name of those working in the area:

Injuries

• Did injuries occur:

  yes

  no

• Were persons injured transported to a medical facility:

  yes

  no

• Mode of transportation:

  Select EMS Employer Other

  • EMS
  • Employer
  • Other

• Name of medical facility, address, city, state, phone number:

Eye witness information:

• Name, address, phone cell/home:

• Eye witness description and diagram of accident or attached photo:

• Photo:

  Media

• Supervisors description of accident and unusual finding including but not limited to all employees or attached photo:

• Photo:

  Media

• Recommendations on corrective actions to prevent similar accidents:

• Safety representative shall provide transportation for the employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).
  
  

• Supervisors signature

  Sign

Slips and Falls

• Slips and Falls

  yes

  no

• Date/Time of incident:

  Date

• Location where incident occurred, job site, city, state:

• Describe injury (nature / body part):

• Treatment:

  Select none first aid only Urgent care hospital

  • none
  • first aid only
  • Urgent care
  • hospital

• Treatment facility Name, Address, City, State. Physician name and phone number:

Incident report

• Photographs:

  yes

  no

• Select scene employees injuries employees shoes

  • scene
  • employees injuries
  • employees shoes

• Add media

  Media

• Description of scene:

• Inspection and description of employees shoes:

• Complaints from employee before the accident/incident:

• Complaints from employee after the accident/incident:

• Accident occurred on:

  Select floor stairs ladder platform other

  • floor
  • stairs
  • ladder
  • platform
  • other

• Describe:

• Description of Accident:

• Weather factors:

  Select N/A sunny rain snow ice sleet wind

  • N/A
  • sunny
  • rain
  • snow
  • ice
  • sleet
  • wind

• Temperature:

• Other factors:

  Select loose sand unlevel terrain hole condesation

  • loose sand
  • unlevel terrain
  • hole
  • condesation

Eye witness information:

• Name, address, phone cell/home:

• Eye witness description and diagram of accident/incident or attached photo:

• Add media

  Media

• Supervisors description and diagram of accident/incident or attached photo:

• Add media

  Media

• Recommendations: supervisor

• Recommendations: employee

• Recommendations: equipment

• Recommendations: environment

• Safety representative shall provide transportation for employee to a drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours).
  

• Supervisors signature

  Sign

Misc incident report

• Misc incident report

  yes

  no

• Date and time of accident

  Date

• Type of incident i.e.: cuts, punctures, etc

• Location of incident, job site, streets town and state

• Describe injury (nature/body part) photos if availabe

• Attach photos if available

  Media

• What type of medical treatment was required

  Select none first aid only Urgent care hospital

  • none
  • first aid only
  • Urgent care
  • hospital

• Treatment facility name, address, city, state, phone number and physicians name

• How was employee transported

  Select EMS Employer Other

  • EMS
  • Employer
  • Other

• Did weather or other factors effect the incident.

  Select yes no N/A

  • yes
  • no
  • N/A

• Describe these conditions

• Describe the type of work the employee was performing at the time of the incident

• Describe the type of tools, equipment being used at the time of the incident

• Describe in the detail the incident and the scene

• Are photos available of the injury and site of the incident, include diagram if possible

  Select yes no N/A

  • yes
  • no
  • N/A

• Attach photos

  Media

• Does this employee have a history of these types of incidents

  yes

  no

  N/A

• Describe

• Does employee follow safety polices at all times

  yes

  no

  N/A

• Describe

• Did employee complain of any symptoms prior to the incident

  yes

  no

  N/A

• Describe

• Did the employee complain of any symptoms after the incident

  yes

  no

  N/A

• Describe

• Was the incident a result of misuse or failure of tools or equipment

  yes

  no

  N/A

• Describe

• Was an immediate drug screen performed

  yes

  no

  N/A

Eye witness information

• Name, address and phone cell/home of any witnesses

• Witness description and diagram of the incident or attached photo

• Photo

  Media

• Supervisors name and phone cell/home

• Supervisors description and diagram of the incident or attached photo

• Photo

  Media

• Recommendations on corrective actions to prevent similar

• Safety representative shall provide transportation for employee to drug testing facility. (If this is a DOT recordable accident, drug and alcohol testing must be done within 2 hours)

• Supervisors signature

  Sign

• Misc incident report

  Yes

  No

  N/A

Root Cause Analysis Report

• Determine root cause: Conduct this investigation with an open mind, and assume the readers know nothing about the accident, workers involved or the accident scene. Focus on the fact, NOT opinion. Provide sufficient details, be clear and concise.

PEOPLE:

• Job Classification:

• Employee Training / Certificates:

• Employee training/certificate

  Media

• Was employee supposed to be in the area?

  yes

  no

• Were tools, materials or equipment misused?

  Yes

  No

  N/A

• Was the correct tool used?

  Yes

  No

  N/A

• Was Personal Protective Equipment used incorrectly, didn't fit properly or was not used?

  Yes

  No

  N/A

PROCESS:

• Describe sequence of steps to perform the task?

• Photos

  Media

• Was there communication for the task (JSA, daily huddle or toolbox talk)?

  yes

  no

• Is it apparent short cuts ere taken and if so what were they?

  yes

  no

• Were there unrecognizable hazards? If so why were they not recognizable?

  yes

  no

• What Watson policies are there for this instance?

Equipment:

• Was equipment inspections performed?

  Yes

  No

  N/A

• What is the conditional of the equipment?

• Any known oddities with the equipment?

  Yes

  No

  N/A

• Was the correct equipment used or was a substituted piece of equipment used in its place?

  Yes

  No

  N/A

• Other equipment factors that may have caused the incident?

Environment:

• What part, if any did other subcontractors, GC or owner play in this incident?

• What part did the public or traffic play in this incident?

• Was weather a factor?

  Yes

  No

  N/A

• Was there adequate space to perform the assigned task?

  Yes

  No

  N/A

• Did the location or positioning of equipment, materials and or employees contribute to this incident?

  Yes

  No

  N/A

• Was the hazard recognized?

  Yes

  No

  N/A

• Were other factors such as noise, illumination and lighting or ventilation a contributing factor?

  Yes

  No

  N/A

• Is the job on schedule?

  yes

  no

Attach supporting materials to your report: Photos / diagrams

• Add media

  Media

Background questions to know the answer to?

• Had this risk been reported before?

  Yes

  No

  N/A

• Have other events occurred at this site?

  Yes

  No

  N/A

• Has this employee been involved in other incidents?

  yes

  no

• Was the problem corrected before? If so by who?

  Yes

  No

  N/A

• Have other incidents occurred with this supervisor?

  yes

  no

• Explain in detail why this incident happened.

• What initiated this incident.

• List series of events that led to this incident?

• What was the last event before the accident?

Incident type?

• Equipment/vehicles

• Near miss

• Occupational injury/illness

• Property damage

This event was the result of:

• Policy

• Communication

• Process

• Equipment

• Training

• Supervision

• Employee

• Subcontractor, GC, Owner, General Public

• Other: explain

• Describe the overall root cause results.

Solutions to eliminate, prevent, minimize the reoccurrence of this incident.

The above must be corrected by the following.

Corrective actions must be completed and implemented.

• At earliest opportunity

• Within 3 days

• Before further use

• Other

• Explain

Root cause report completed by

• Signature

  Sign