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 Incident report (misc)

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

• Conducted on

  Date

• Prepared by

• Accident Date / Time

  Date

• Division:

• Job site:

• Date report complete:

  Date

• Employee name:

• Employee contact information:

• Employee identification number:

• Job Title:

• Supervisor/foreman name contact information:

• Summary of the accident

• Recommended corrective action

• 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?

  Select Pedestrain Head on Read End Single Car Other property

  • Pedestrain
  • Head on
  • Read End
  • Single Car
  • Other property

• Measurement of skid marks:

• Photographs from accident scene:

  Media

• Comments

• Skid marks made from other parties involved in accident:

  yes

  no

• Photo of skid marks:

  Media

• Comments:

• 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

• Watson operators description of the accident:

Injuries

• Did injuries occur?

  yes

  no

• Names and contact information for those injured:

• Description of the injury/injuries

• Photo of injuries if available:

  Media

• 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 and contact information:

• Eye witness description and diagram of accident:

• Photo

  Media

• Supervisors/Foreman’s description and diagram of accident with any unusual findings: illegal substances, no drivers license with driver or attach 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).

Burn Incident Report

• Burn incident report

  yes

  no

• Date and time of Burn incident

  Date

• Type of burn?

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

• What caused the burn?

• Voltage was tested by?

• Description of voltage meter:

• What procedures were used to test the voltage?

• Indicate measurement of voltage?

• Rubber gloves worn by employee?

  yes

  no

• Glove test date:

  Date

• Photo of gloves

  Media

• Were rubber blankets used?

  yes

  no

• Rubber blanket test date:

  Date

• Photo of blanket:

  Media

• Were there burn marks on the employees clothing?

  yes

  no

• Comments

• Photo of employees clothes:

  Media

• Employee description of the incident:

  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

  N/A

• Names and contact information for those injured?

• Description of the injury/injuries?

• Photo of injuries if available

  Media

• Were persons injured transported to a medical facility?

  yes

  no

  N/A

• Mode of transportation?

  EMS

  Employer

  Other

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

Eye witness information:

• Name and contact information:

• Eyewitness description and diagram of accident:

• Photo

  Media

• Supervisor/Foreman’s description and diagram of accident with any 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)

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 and job name:

• Intersection if applicable:

• Was cut line active:

  yes

  no

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

  yes

  no

• Was the cut line located on private property?

  yes

  no

• Comments

• Were photos taken prior to work beginning?

  yes

  no

• Photos

  Media

• 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 locate ticket was updated:

  Date

• Name and contact information of persons updating the locate ticket:

Other Companies involved in project:

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

Injuries

• Did injuries occur?

  yes

  no

• Description of the injuries:

• Photos of the injuries:

  Media

• Names and contact information 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 and contact information:

• Eye witness description of accident or attached photo:

• Photo

  Media

• Supervisors/Foreman’s 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 actions 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.

Exposure Incident

• Exposure incident

  yes

  no

• Date / Time of exposure:

  Date

• Location of where exposure occurred: Street, Town, State and job name:

• Were SDS sheets available?

  yes

  no

• Type of exposure / material?

• Was area contaminated and / or isolated?

  yes

  no

• Comments

• 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

• Description of symptoms:

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

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

  yes

  no

• Description of symptoms or complaints:

• Were there others working in the exposed area?

  yes

  no

• List names of contact information of others working in the exposed area:

• 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

• Description of injuries:

• Photos of injuries

  Media

• Were persons injured transported to 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 and contact information:

• Eye witness description and diagram of accident:

• Photo of accident:

  Media

• Supervisor/Foreman’s 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).

Heat Stroke, Heat Exhaustion, Heart Attack

• Heat Stoke, Heat Exhaustion, Heart Attack

  yes

  no

• Location of incident: Street, Town, State and job name:

• Time employee arrived at work site:

  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

• Comments

• History of heart disease or stroke:

  yes

  no

• Comments:

• Weather factors:

  Select n/a sun rain snow ice sleet wind

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

• Temperature:

• Was water available on the job site?

  yes

  no

• Location of water source in relation to the work area:

• Why was water not available?

• If employee wasn’t drinking water what type of beverage did he consume the day of the event?

Supervisors description of accident:

• 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:

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

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

  yes

  no

• If yes describe:

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

  yes

  no

• If yes, describe in detail:

Injuries

• Did injury occur:

  yes

  no

• Description of the injuries:

• Photo of injuries:

  Media

• 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 and contact information:

• Eye witness description of incident or attached photo:

• Photo:

  Media

• Supervisor/Foreman’s description of the event with any unusual findings:

• Photo of the site of the incident;

  Media

• 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).

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

• Describe:

• 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:

• Description of scene:

• Photos of scene:

  Media

• Description of working being performed at time of incident:

• Complaints from employee before accident/incident?

• Complaints from employee after accident/incident?

• Conditions of the work area:

• Description of what employee was lifting and approximate weight?

• Inspection and type of shoes employee was wearing:

• Photo of shoes:

  Media

• Has employee requested time off before this alleged accident:

  yes

  no

• What discussion about lifting and lifting techniques to use?

  yes

  no

• Weather factors:

  Select N/A sunny rain snow ice sleet wind

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

• Other factors:

  Select loose sand unlevel terrain holes condensation Other

  • loose sand
  • unlevel terrain
  • holes
  • condensation
  • Other

• Comments:

Eye witness information:

• Name and contact information:

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

• Photo of scene:

  Media

• Supervisor/Foreman’s description of accident/incident and diagram and any unusual findings and 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).

Repetitive Trauma

• Repetitive Trauma

  yes

  no

• Date/Time of incident:

  Date

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

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

• Was alternate methods, rotation of employee etc considered to lessen impact of this task to the employee?

  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

• Comments:

• 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

• What were the symptoms/complaints?

• Does the employee have any other health issues?

  yes

  no

• What are these issues?

• Does the employee have a history of following safety policies?

  yes

  no

• Explain concerns?

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

  yes

  no

• What are these violations?

• Were there other employees working in the area?

  yes

  no

• List name of those working in the area:

Injuries

• Did injuries occur?

  yes

  no

• Description of the injuries:

• Were persons injured transported to a medical facility?

  Select yes no

  • 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 and contact information:

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

• Photo:

  Media

• Supervisor/Foreman’s description of accident and any unusual findings and 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).
  
  

Slips and Falls

• Slips and Falls

  yes

  no

• Date/Time of incident:

  Date

• Location where incident occurred, job name, city, state and job name:

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?

• Photo of shoes

  Media

• 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 holes condensation Other

  • loose sand
  • unlevel terrain
  • holes
  • condensation
  • Other

Injuries

• Description of the injuries:

• Were injured personnel transported to medical facility?

  yes

  no

  N/A

• Mode of transportation:

  EMS

  Employer

  Other

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

Eye witness information:

• Name and contact information:

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

• Photo of scene:

  Media

• Supervisor/Foreman’s description and diagram of accident/incident or attached photo:

• Photo

  Media

• Recommendation on corrective actions to prevent similar accidents:

• 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).
  

Incident report (misc)

• Incident report (misc)

  yes

  no

• Date and time of incident:

  Date

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

• Location of incident, job name, street, town and state:

• 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:

• Photos if available

  Media

• Describe in the detail the incident and the scene:

• Photos of the scene if available

  Media

• 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 employees history:

• Does employee have a history of following safety polices?

  yes

  no

  N/A

• Describe:

• Did employee complain of any symptoms prior to the incident?

  yes

  no

  N/A

• Describe the symptoms or complaints:

• Did the employee complain of any symptoms after the incident?

  yes

  no

  N/A

• Describe symptoms or complaints:

• Were equipment or tools misused?

  yes

  no

  N/A

• Describe how tools and equipment was misused:

• Was an immediate drug screen performed?

  yes

  no

  N/A

Injuries

• Did injuries occur?

  yes

  no

  N/A

• Comments:

• Photo of injuries:

  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

Eye witness information

• Name and contact information:

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

• Photo

  Media

• Supervisor/Foreman’s description and diagram of the accident or attached 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)

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 if so list types used:

  Yes

  No

  N/A

• List PPE used:

PROCESS:

• Describe sequence of steps to perform the task?

• Photos, describe incident site or re enactment

  Media

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

  Yes

  No

  N/A

• Comments

• If yes then attach photo of document:

  Media

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

  yes

  no

• What short cuts were taken:

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

  yes

  no

• If yes explain the hazard:

• What Watson policies are there for this instance?

Equipment:

• Was equipment inspections performed?

  Yes

  No

  N/A

• If not, then why not:

• What is the conditional of the equipment?

• Any known oddities with the equipment?

  Yes

  No

  N/A

• If yes, what are they:

• Was the correct equipment used:

  Yes

  No

  N/A

• Describe:

• 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

• If yes, then what:

• Have other events occurred at this site?

  Yes

  No

  N/A

• If yes, then why:

• Has this employee been involved in other incidents?

  yes

  no

• If yes, what incident:

• Was the problem corrected before?

  Yes

  No

  N/A

• If yes, correct by who:

• Have other incidents occurred with this supervisor?

  yes

  no

• If yes, what are the other incidents:

• 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.

• Immediately

• Before further use

• Within 3 days

• At earliest opportunity

• Other

• Explain:

Root cause report completed by

• Safety Officers Signature

  Sign

• Signature from Division acknowledging this has been corrected / implemented

  Sign