Title Page
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Site conducted
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Department
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Region
- North
- Central
- South
- FD
- KFF
- Medina
- NDC
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Investigation manager
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Part 1 Incident number
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Incident date
Untitled Page
Accident severity
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Accident Severity
- Major Specified
- RIDDOR
- 3-7 Day
- 1-3 Day
- Minor
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Riddor reference number
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Upload RIDDOR document
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Has a home visit been completed?
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Please explain why
About the Injured Person
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Injured person's name
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Is the injured Person Agency staff
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Employee Number
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Job Title
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Department
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Length of Service
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Normal Working hours
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Time employee commenced work that day:
Details of Incident
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Details of the Incident (from your findings, include events leading up to, during and following the incident)
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Task being completed
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Details of Injury
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Body Part (please include left/right detail)
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Location of incident (e.g. On Site / Off Site)
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Manager/Supervisor of Area
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Address and Location (e.g., rear of vehicle / customer premises / roadside etc.)
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Accident Category Type
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Please specify
Investigation
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SECTION D- What activities were being carried out at the time
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Were there any substances involved?
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Were there any loads being carried? (give weights, sizes and dimensions)
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SECTION E - Identify Underlying Causes: (To be completed by Depot Manager /Operations Manager/Department Manager/Team Leader) - Section E-paper copy Management or supervision failure? Lack of competence? Inadequate training? Was there a fault in the original design? Absence of a system for maintenance?
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SECTION F - Actions Needed to Prevent a Recurrence: (To be completed by Depot Manager /Operations Manager/Department Manager/Team Leader) - Section F Paper copy Could the accident have been more serious and what prevented this from happening? Improve physical safeguards? Use mechanical handling aids? Introduce better test and maintenance arrangements. Improve work methods? Provide and use personal protective equipment (PPE)? Make changes to supervision and training arrangements. Review similar risks in other departments. Review procedures involving contractors? Update standards and policies? Assess/re-assess the risks. There is no need to carry out a new risk assessment if the existing assessment is sufficient and adequate.
Please follow the instructions below to send a notification to the GM who can then complete the next section.
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Click to submit to GM on completion of investigation only
- Aylesford
- Bodmin
- Bridgend
- Brighton
- Ashford
- Corby
- Bodelwyddan
- Deeside
- Dundee
- Durham
- Eastleigh
- Grantham
- Harlow
- Hemsworth
- Inverness
- Newark
- Newhouse
- Covent Garden
- Peterlee
- Portbury
- Premier park
- Reading
- Ripon
- Tamworth
- Thetford
- Warrington
- Medina IOW
- Medina Southampton
- KFF Aylesford
- KFF Witney
- Bicester
- Dagenham
- Wigan
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SECTION G - Management response: (To be completed by Depot Manager/Operations Manager) - Section G paper copy Establish whether the initial management response was adequate. Was there relevant prompt and appropriate action such as making safe and dealing with continuing risks, electrical isolation, suitable fire fighting, effective first aid response, correct spillage procedure? Was the correct accident investigation procedure followed?
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SECTION H - Agreed Course of Action: (To be completed by Depot Manager/Operations Manager) - Section H paper copy
Confirm the following have been saved to the accident pack
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First aid statement
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Reason
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Injured persons statement
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Reason
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Witness statements
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Reason
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SAM's Observations/TRACA (prior to incident)
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Reason
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CCTV Checks (Driver/Warehouse)
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Reason
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CCTV footage of area/ Incident
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Reason
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Has an re-enactment of the incident been recorded?
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Reason
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Photographs captured of area at the time of incident
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Reason
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Photographs captured of the injury including comparison photos.
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Reason
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Training Documents
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Reason
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Re-training Documents (post accident)
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Reason
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Communications with EHO/HSE, inc RIDDOR form
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Reason
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Machinery/Vehicle maintenance records/specifications* (PUWER)
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Reason
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Documents arising from investigation outcome - Briefings, hazard alerts etc.
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Have the relevant risk assessments been reviewed?
Supporting Documents
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Communications with DSS
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Attendance records (individual or depot records)
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Disciplinary records (connected with, or arising after the accident)
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Termination records
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Information circulated to all depot employees after incident*
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Cleaning/Housekeeping schedules prior to incident*
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Local H & S Committee minutes
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Depot risk assessments Pre and Post Accident
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COSHH data sheets*
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Documents relating to the provision & maintenance of protective equipment (PPE)*
Summary
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Additional Comments
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I confirm that, to the best of my knowledge, this investigation has been fully completed. All relevant documents have been saved. The management questionnaire document HS1012 has been completed and saved in the secure folder.
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Site General Manager Signature
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Date and Time
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Did the incident incur more than 7 days absence and/or a major/specified injury? If yes, you must forward this on to your HSBP
- No
- Action created for HSBP to close
