Accident Investigation Report

• Accident Details

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

• MyTycoEHS Number:

CONTACTS & INFO ON HOW TO INVESTIGATE

• Prime objective of investigation is prevention. What caused the incident so it can be prevented in future. Goal is collect information, not assign blame.

• EMERGENCY CONTACT INFO:
  Ambulance, fire, police: 911
  Enbridge Gas emergency: 1-866-763-5427
  Hydro One emergency: 1-800-434-1235
  MOL hotline: 1-877-202-0008
  

• GS office contacts:
  Office: 705-741-1700
  Simon Boone: m. 705-927-7122
  JP Pawliw: m. 705-931-3902

• SECURE THE SCENE - deal with injuries and threat if further injuries, crowd control and isolate the scene. Do not move anything unless absolutely necessary.
  IDENTIFY WITNESSES - make list of witnesses and people who were in the area immediately.

• First Aider involved?

  Yes

  No

  N/A

• Name and contact of First Aider

• Reported to hospital?

  Yes

  No

  N/A

• Name and contact of Hospital

• Reported to family/emergency contact?

  Yes

  No

  N/A

• Name and contact info of person you spoke to

• When?

  Date

• Reported to MOL?

  Yes

  No

  N/A

• Name and contact of MOL rep who you spoke with

• When?

  Date

• Any Witnesses?

  Yes

  No

  N/A

• Names and contact info of witnesses:

• Reported to supervisor/management?

  Yes

  No

  N/A

• Who did you report it to?

• When?

  Date

• Reported to anyone else?

  Yes

  No

  N/A

• Who else received report of incident? Include name and contact details.

• When?

  Date

WHEN AND WHERE DID INCIDENT OCCUR?

• DATE & TIME OF INCIDENT

  Date
• LOCATION OF INCIDENT
  Address

• SURVEY THE SCENE - use sketches, camera, measuring tape. Describe actions and parameters leading up to incident - task being completed, weather and site conditions, location on the site, other people present, any other contributing factors (only the facts, do not speculate)
  GATHER PHYSICAL EVIDENCE - do not move anything, take photos

• Scene survey

• Sketch of scene

  Drawing

• Photos of scene

  Media

OBSERVATIONS

• OBSERVATIONS

  Select Inadequate guarding Inadequate lighting Inadequate/lack of training Inadequate/lack of work procedures Exposure to electricity Use of incorrect tools/equipment Incorrect manual handling equipment Lack of supervision Exposure to chemicals/hazardous substances Exposure to sound/noise Congested Work areas/poor housekeeping Faulty equipment/materials Lack of PPE Fire/Explosion No Risk Assessments No safety equipment Other

  • Inadequate guarding
  • Inadequate lighting
  • Inadequate/lack of training
  • Inadequate/lack of work procedures
  • Exposure to electricity
  • Use of incorrect tools/equipment
  • Incorrect manual handling equipment
  • Lack of supervision
  • Exposure to chemicals/hazardous substances
  • Exposure to sound/noise
  • Congested Work areas/poor housekeeping
  • Faulty equipment/materials
  • Lack of PPE
  • Fire/Explosion
  • No Risk Assessments
  • No safety equipment
  • Other

• Describe anything else you observed when you saw the site of the incident (post incident)

• Other Details:

• Add photos

  Media

SEQUENCE OF EVENTS

• SEQUENCE OF EVENTS

INDICATION OF INJURIES

• WERE THERE ANY INJURIES?

  YES

  NO

• SELECT AREA OF INJURY:

  Select 1) Head 2) Neck 3) Chest 4) Adbomen 5) Shoulder 6) Arms 7) Elbow 8) Forearm 9) Wrist 10) Hand 11) Hip 12) Thigh 13) Knee 14) Calf 15) Top of foot 16) Foot 17) Nape 18) Lumber region 19) Buttock

  • 1) Head
  • 2) Neck
  • 3) Chest
  • 4) Adbomen
  • 5) Shoulder
  • 6) Arms
  • 7) Elbow
  • 8) Forearm
  • 9) Wrist
  • 10) Hand
  • 11) Hip
  • 12) Thigh
  • 13) Knee
  • 14) Calf
  • 15) Top of foot
  • 16) Foot
  • 17) Nape
  • 18) Lumber region
  • 19) Buttock

• DETAILS OF INJURY:

• PHOTOGRAPHS OF INJURY

  Media

INDICATION OF DAMAGE TO PROPERTY

• WAS THERE ANY DAMAGE TO PROPERTY?

  YES

  NO

• RECORD DETAILS AND EXTENT OF DAMAGE

• PHOTOGRAPHS OF DAMAGE

  Media

WITNESSES

• WERE THERE ANY WITNESSES?

  YES

  NO

• INTERVIEW WITNESSES - do this as soon as possible in a private spot. Be thorough and inquisitive. Reassure purpose of interview is fact finding, not fault finding. Let witness tell story twice. Take notes on the second telling.
  Ask witnesses for actions and parameters leading up to incident - task being completed, weather and site conditions, location on the site, other people present, any other contributing factors (differentiate between facts and speculations)

• RECORD DETAILS OF WITNESSES

• Add photos

  Media

CONCLUSIONS

• Describe the immediate cause (ie., slip or trip) and then the underlying cause (area was not kept clean/dry)

• CONCLUSIONS:

RECOMMENDATIONS

• Recommendations/ corrective actions must apply to the underlying cause of the incident as well as the immediate cause.

• RECOMMENDATIONS:

FURTHER ACTIONS

• List specific actionable items. Include who is to undertake and timeline for completion.

• FURTHER ACTIONS

  Select Establish underlying cause Create Safety Talk about this incident Verification of actions taken required at next audit Request 3rd party safety audit

  • Establish underlying cause
  • Create Safety Talk about this incident
  • Verification of actions taken required at next audit
  • Request 3rd party safety audit

• More space here

PHOTOGRAPHS

• Any additional photos?

  Yes

  No

  N/A

• Additional photos

  Media

REPORT COMPLETED BY

• INVESTIGATION COMPLETED BY:

  Sign

• DATE SIGNED

  Date

• CIRCULATE REPORT - send to management and supervisors so all can learn.