Accident/Incident Investigation

• Accident/Incident Details

• Client / Site

• Location
  Address

• Conducted on

  Date

• Prepared by

• Take as many photos of the scene as possible.

Introduction.

• Location of Incident
  Address

• Date and Time of Incident

  Date

• Describe scope of works and task being completed at time of Accident/Incident.

Accident/Incident Investigation.

• Describe who, what, why and how the accident/incident occurred?

Indication of Injuries.

• Was 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

Indication of Damage to Property.

• Was there any Damage to Plant or Equipment?

  YES

  NO

• Record details and extent of Damage

Witnesses.

• Were there any Witnesses?

  YES

  NO

• Witness Statement.

• Name & Signature of Witness.

  Sign

Observations (include any contributing factors).

• 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 Failure to comply with Work Procedure 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
  • Failure to comply with Work Procedure
  • Other

• Provide Details?

Corrective Actions.

Short Term Action.

• What was the immediate action taken to correct the issue?

Long Term Action.

• What is the long term action needed to correct the issue?

Report Completed By.

• Investigation Completed by:

  Sign

• Date of Investigation Report.

  Date