AP-Incident Report

• Document No.

PERSON REPORTING THE INCIDENT

• Report completed by

• Contact number

• Email address

INCIDENT DETAILS

• Name of injured person

• Job number

• Location of the incident
  Address

• Date and time of the of the incident

  Date

• Near Miss Report

Near Miss Report

• Reporting accidents and incidents at work
  http://www.hse.gov.uk/pubns/indg453.pdf

About the incident

• In which department or where on the premises did the incident happen?
  Address

• Details of the work activity that led to the occurrence:

• Describe what happened:

• Potential outcome

  Property damage

  Minor injury

  Over 7 days absence

  Hospital admission

  Death

• Environmental Incident Report

Environmental Incident Report

• Report an environmental incident
  https://www.gov.uk/report-an-environmental-incident

About the incident

• In which department or where on the premises did the incident happen?
  Address

• Details of the work activity that led to the occurrence:

• Nature of the occurrence

  Select Contamination of land, flora, fauna Damage to archaeology, listed building, local heritage etc Emission to air of gas, dust, fumes or other pollutants Explosion Fire Noise, litter, light, odour, vibration or other nuisance Pollution of water courses, surface water drains, foul water sewers Spillage of special, hazardous or restricted substances (eg oil, detergent, paint) Spillage, leakage or uncontrolled discharge of substances Waste management (escape or improper storage/disposal) Other risk

  • Contamination of land, flora, fauna
  • Damage to archaeology, listed building, local heritage etc
  • Emission to air of gas, dust, fumes or other pollutants
  • Explosion
  • Fire
  • Noise, litter, light, odour, vibration or other nuisance
  • Pollution of water courses, surface water drains, foul water sewers
  • Spillage of special, hazardous or restricted substances (eg oil, detergent, paint)
  • Spillage, leakage or uncontrolled discharge of substances
  • Waste management (escape or improper storage/disposal)
  • Other risk

• Specify nature of the occurrence

• Describe what happened:

• Property Damage Report

Property Damage Report

• Reporting accidents and incidents at work
  http://www.hse.gov.uk/pubns/indg453.pdf

• If an injury resulted, please fill in the accident report instead.

About the incident

• In which department or where on the premises did the incident happen?
  Address

• Details of the work activity that led to the damage:

• What damage was sustained?

• How was the damage sustained?

• Accident Report

Accident Report

• Reporting accidents and incidents at work
  http://www.hse.gov.uk/pubns/indg453.pdf

About the accident

• In which department or where on the premises did the accident happen?
  Address

• Type of accident

  Select Contact with electricity or an electrical discharge Contact with moving machinery or material being machined Drowned or asphyxiated Exposed to an explosion Exposed to fire Exposed to, or in contact with, a harmful substance Fell from a height Hit by a moving vehicle Hit by a moving, flying or falling object Hit something fixed or stationary Injured by an animal Injured while handling, lifting or carrying Physically assaulted by a person Slipped, tripped or fell on the same level Trapped by something collapsing Other kind of accident

  • Contact with electricity or an electrical discharge
  • Contact with moving machinery or material being machined
  • Drowned or asphyxiated
  • Exposed to an explosion
  • Exposed to fire
  • Exposed to, or in contact with, a harmful substance
  • Fell from a height
  • Hit by a moving vehicle
  • Hit by a moving, flying or falling object
  • Hit something fixed or stationary
  • Injured by an animal
  • Injured while handling, lifting or carrying
  • Physically assaulted by a person
  • Slipped, tripped or fell on the same level
  • Trapped by something collapsing
  • Other kind of accident

• Specify other kind of accident

• Details of the work activity that led to the accident:

• Describe what happened:

About the injured person

• Name

• Home Address
  Address

• Phone number

• Email

• Occupation or job title

• Gender

  Male

  Female

• Age

• Work status

  Select Employee Sub contractor Other contractor Visitor Member of the public Self employed

  • Employee
  • Sub contractor
  • Other contractor
  • Visitor
  • Member of the public
  • Self employed

• Did the member of the public need hospital treatment?

  Yes

  No

• This is a RIDDOR reportable accident, inform the H&S Manager ASAP.
  Email: rodrigomelo@abbeypynford.co.uk
  Phone: 07970 916 767

About the injury

• Severity of the injury

  Low

  Medium

  High

• Injury type

  Select Abrasion Amputation Asphyxiation Bite / Sting Bruise / Bump Burn / Scald Crush Cut / laceration Dislocation Electrical shock Fracture Internal injury Loss of consciousness Loss of sight Puncture Strain / Sprain Other injury

  • Abrasion
  • Amputation
  • Asphyxiation
  • Bite / Sting
  • Bruise / Bump
  • Burn / Scald
  • Crush
  • Cut / laceration
  • Dislocation
  • Electrical shock
  • Fracture
  • Internal injury
  • Loss of consciousness
  • Loss of sight
  • Puncture
  • Strain / Sprain
  • Other injury

• Specify other injury type

• Part of the body affected

  Select Ankle Arm Back Buttocks Chest Eye Face Finger(s) Foot Groin Hand Head Hip Internal injuries Knee Leg Multiple injuries Neck Shin Shoulder Stomach Thigh Toe(s) Wrist

  • Ankle
  • Arm
  • Back
  • Buttocks
  • Chest
  • Eye
  • Face
  • Finger(s)
  • Foot
  • Groin
  • Hand
  • Head
  • Hip
  • Internal injuries
  • Knee
  • Leg
  • Multiple injuries
  • Neck
  • Shin
  • Shoulder
  • Stomach
  • Thigh
  • Toe(s)
  • Wrist

RIDDOR specified injuries

• Specified injuries to workers
  http://www.hse.gov.uk/riddor/specified-injuries.htm

• Did a RIDDOR specified injury happened?

  Select No Away from normal work more than 7 days a fracture, other than to fingers, thumbs and toes; amputation of an arm, hand, finger, thumb, leg, foot or toe; permanent loss of sight or reduction of sight; crush injuries leading to internal organ damage; any burns (covering more than 10% of the body, or damaging the eyes, respiratory system or other vital organs); scalpings (separation of skin from the head) which require hospital treatment; unconsciousness caused by head injury or asphyxia; any other injury arising from working in an enclosed space, which leads to hypothermia, heat-induced illness or requires resuscitation or admittance to hospital for more than 24 hours.

  • No
  • Away from normal work more than 7 days
  • a fracture, other than to fingers, thumbs and toes;
  • amputation of an arm, hand, finger, thumb, leg, foot or toe;
  • permanent loss of sight or reduction of sight;
  • crush injuries leading to internal organ damage;
  • any burns (covering more than 10% of the body, or damaging the eyes, respiratory system or other vital organs);
  • scalpings (separation of skin from the head) which require hospital treatment;
  • unconsciousness caused by head injury or asphyxia;
  • any other injury arising from working in an enclosed space, which leads to hypothermia, heat-induced illness or requires resuscitation or admittance to hospital for more than 24 hours.

• If the injury didn't happen to a member of the public who needed hospital treatment as a result of this accident, then this is not a RIDDOR reportable accident.

• This is a RIDDOR reportable accident, inform the H&S Manager ASAP.
  Email: rodrigomelo@abbeypynford.co.uk
  Phone: 07970 916 767

• Dangerous Occurrence Report (RIDDOR)

Dangerous Occurrence Report (RIDDOR)

• Reporting accidents and incidents at work
  http://www.hse.gov.uk/pubns/indg453.pdf

• This is a RIDDOR reportable incident, inform the H&S Manager ASAP.
  Email: rodrigomelo@abbeypynford.co.uk
  Phone: 07970 916 767

About the incident

• In which department or where on the premises did the incident happen?
  Address

• Dangerous Occurrences
  http://www.legislation.gov.uk/uksi/2013/1471/schedule/2/made

• Tick to view RIDDOR definition for Dangerous Occurrences, Untick to close.

• Lifting equipment

• 1. The collapse, overturning or failure of any load-bearing part of any lifting equipment, other than an accessory for lifting.

• Pressure systems

• 2. The failure of any closed vessel or of any associated pipework (other than a pipeline) forming part of a pressure system as defined by regulation 2(1) of the Pressure Systems Safety Regulations 2000(1), where that failure could cause the death of any person.

• Overhead electric lines

• 3. Any plant or equipment unintentionally coming into—
  
  (a)contact with an uninsulated overhead electric line in which the voltage exceeds 200 volts; or
  
  (b)close proximity with such an electric line, such that it causes an electrical discharge.

• Electrical incidents causing explosion or fire

• 4. Any explosion or fire caused by an electrical short circuit or overload (including those resulting from accidental damage to the electrical plant) which either—
  
  (a)results in the stoppage of the plant involved for more than 24 hours; or
  
  (b)causes a significant risk of death.

• Explosives

• 5. Any unintentional—
  
  (a)fire, explosion or ignition at a site where the manufacture or storage of explosives requires a licence or registration, as the case may be, under regulation 9, 10 or 11 of the Manufacture and Storage of Explosives Regulations 2005; or
  
  (b)explosion or ignition of explosives (unless caused by the unintentional discharge of a weapon, where, apart from that unintentional discharge, the weapon and explosives functioned as they were designed to),
  
  except where a fail-safe device or safe system of work prevented any person being endangered as a result of the fire, explosion or ignition.
  
  6. The misfire of explosives (other than at a mine or quarry, inside a well or involving a weapon) except where a fail-safe device or safe system of work prevented any person being endangered as a result of the misfire.
  
  7. Any explosion, discharge or intentional fire or ignition which causes any injury to a person requiring first-aid or medical treatment, other than at a mine or quarry.
  
  8.—
  (1) The projection of material beyond the boundary of the site on which the explosives are being used, or beyond the danger zone of the site, which caused or might have caused injury, except at a quarry.
  
  (2) In this paragraph, “danger zone” means the area from which persons have been excluded or forbidden to enter to avoid being endangered by any explosion or ignition of explosives.
  
  9. The failure of shots to cause the intended extent of collapse or direction of fall of a structure in any demolition operation.

• Biological agents

• 10. Any accident or incident which results or could have resulted in the release or escape of a biological agent likely to cause severe human infection or illness.

• Radiation generators and radiography

• 11.—
  
  (1) The malfunction of—
  
  (a)a radiation generator or its ancillary equipment used in fixed or mobile industrial radiography, the irradiation of food or the processing of products by irradiation, which causes it to fail to de-energise at the end of the intended exposure period; or
  
  (b)equipment used in fixed or mobile industrial radiography or gamma irradiation, which causes a radioactive source to fail to return to its safe position by the normal means at the end of the intended exposure period.
  
  (2) In this paragraph, “radiation generator” means any electrical equipment emitting ionising radiation and containing components operating at a potential difference of more than 5kV.

• Breathing apparatus

• 12. The malfunction of breathing apparatus—
  
  (a)where the malfunction causes a significant risk of personal injury to the user; or
  
  (b)during testing immediately prior to use, where the malfunction would have caused a significant risk to the health and safety of the user had it occurred during use,
  
  other than at a mine.

• Diving operations

• 13. The failure, damaging or endangering of—
  
  (a)any life support equipment, including control panels, hoses and breathing apparatus; or
  
  (b)the dive platform, or any failure of the dive platform to remain on station,
  which causes a significant risk of personal injury to a diver.
  
  14. The failure or endangering of any lifting equipment associated with a diving operation.
  
  15. The trapping of a diver.
  
  16. Any explosion in the vicinity of a diver.
  
  17. Any uncontrolled ascent or any omitted decompression which causes a significant risk of personal injury to a diver.

• Collapse of scaffolding

• 18. The complete or partial collapse (including falling, buckling or overturning) of—
  
  (a)a substantial part of any scaffold more than 5 metres in height;
  
  (b)any supporting part of any slung or suspended scaffold which causes a working platform to fall (whether or not in use); or
  
  (c)any part of any scaffold in circumstances such that there would be a significant risk of drowning to a person falling from the scaffold.

• Train collisions

• 19. The collision of a train with any other train or vehicle, other than a collision reportable under Part 5 of this Schedule, which could have caused the death, or specified injury, of any person.

• Wells

• 20. In relation to a well (other than a well sunk for the purpose of the abstraction of water)—
  
  (a)a blow-out (which includes any uncontrolled flow of well-fluids from a well);
  
  (b)the coming into operation of a blow-out prevention or diversion system to control flow of well-fluids where normal control procedures fail;
  
  (c)the detection of hydrogen sulphide at a well or in samples of well-fluids where the responsible person did not anticipate its presence in the reservoir drawn on by the well;
  
  (d)the taking of precautionary measures additional to any contained in the original drilling programme where a planned minimum separation distance between adjacent wells was not maintained; or
  
  (e)the mechanical failure of any part of a well whose purpose is to prevent or limit the effect of the unintentional release of fluids from a well or a reservoir being drawn on by a well, or whose failure would cause or contribute to such a release.

• Pipelines or pipeline works

• 21. In relation to a pipeline or pipeline works—
  
  (a)any damage to, accidental or uncontrolled release from or inrush of anything into a pipeline;
  
  (b)the failure of any pipeline isolation device, associated equipment or system; or
  
  (c)the failure of equipment involved with pipeline works,
  which could cause personal injury to any person, or which results in the pipeline being shut down for more than 24 hours.
  
  22. The unintentional change in position of a pipeline, or in the subsoil or seabed in the vicinity, which requires immediate attention to safeguard the pipeline’s integrity or safety.

• Structural collapse

• 23. The unintentional collapse or partial collapse of—
  
  (a)any structure, which involves a fall of more than 5 tonnes of material; or
  
  (b)any floor or wall of any place of work,
  
  arising from, or in connection with, ongoing construction work (including demolition, refurbishment and maintenance), whether above or below ground.
  
  24. The unintentional collapse or partial collapse of any falsework.

• Explosion or fire

• 25. Any unintentional explosion or fire in any plant or premises which results in the stoppage of that plant, or the suspension of normal work in those premises, for more than 24 hours.

• Release of flammable liquids and gases

• 26. The sudden, unintentional and uncontrolled release—
  
  (a)inside a building—
  
  (i)of 100 kilograms or more of a flammable liquid;
  
  (ii)of 10 kilograms or more of a flammable liquid at a temperature above its normal boiling point;
  
  (iii)of 10 kilograms or more of a flammable gas; or
  
  (b)in the open air, of 500 kilograms or more of a flammable liquid or gas.

• Hazardous escapes of substances

• 27. The unintentional release or escape of any substance which could cause personal injury to any person other than through the combustion of flammable liquids or gases.

• Select category

  Select Lifting equipment Pressure systems Overhead electric lines Electrical incidents causing explosion or fire Explosives Biological agents Radiation generators and radiography Breathing apparatus Diving operations Collapse of scaffolding Train collisions Wells Pipelines or pipeline works Structural collapse Explosion or fire Release of flammable liquids and gases Hazardous escapes of substances

  • Lifting equipment
  • Pressure systems
  • Overhead electric lines
  • Electrical incidents causing explosion or fire
  • Explosives
  • Biological agents
  • Radiation generators and radiography
  • Breathing apparatus
  • Diving operations
  • Collapse of scaffolding
  • Train collisions
  • Wells
  • Pipelines or pipeline works
  • Structural collapse
  • Explosion or fire
  • Release of flammable liquids and gases
  • Hazardous escapes of substances

• Details of the work activity that led to the occurrence:

• Describe what happened:

• Occupational Disease Report (RIDDOR)

Occupational Disease Report (RIDDOR)

• Reporting accidents and incidents at work
  http://www.hse.gov.uk/pubns/indg453.pdf

• Occupational diseases
  http://www.hse.gov.uk/riddor/occupational-diseases.htm

• This is a RIDDOR reportable incident, inform the H&S Manager ASAP.
  Email: rodrigomelo@abbeypynford.co.uk
  Phone: 07970 916 767

About the injured person

• Name

• Occupation or job title?

• Gender

  Male

  Female

• Age

• Work status

  Select Employee Sub contractor Other contractor Visitor Member of the public Self employed

  • Employee
  • Sub contractor
  • Other contractor
  • Visitor
  • Member of the public
  • Self employed

• Date the disease was diagnosed / confirmed

  Date

• Exposure to carcinogens, mutagens and biological agents?

  Yes

  No

• Specify the diagnosed disease

  Select (a) Carpal Tunnel Syndrome, where the person's work involves regular use of percussive or vibrating tools; (b) cramp in the hand or forearm, where the person's work involves prolonged periods of repetitive movement of the fingers, hand or arm; (c) occupational dermatitis, where the person's work involves significant or regular exposure to a known skin sensitiser or irritant; (d) Hand– Arm Vibration Syndrome, where the person's work involves regular use of percussive or vibrating tools, or the holding of materials which are subject to percussive processes, or processes causing vibration; (e) occupational asthma, where the person's work involves significant or regular exposure to a known respiratory sensitiser; or (f) tendonitis or tenosynovitis in the hand or forearm, where the person's work is physically demanding and involves frequent, repetitive movements.

  • (a) Carpal Tunnel Syndrome, where the person's work involves regular use of percussive or vibrating tools;
  • (b) cramp in the hand or forearm, where the person's work involves prolonged periods of repetitive movement of the fingers, hand or arm;
  • (c) occupational dermatitis, where the person's work involves significant or regular exposure to a known skin sensitiser or irritant;
  • (d) Hand– Arm Vibration Syndrome, where the person's work involves regular use of percussive or vibrating tools, or the holding of materials which are subject to percussive processes, or processes causing vibration;
  • (e) occupational asthma, where the person's work involves significant or regular exposure to a known respiratory sensitiser; or
  • (f) tendonitis or tenosynovitis in the hand or forearm, where the person's work is physically demanding and involves frequent, repetitive movements.

• Specify the diagnosed disease

  (a) any cancer attributed to an occupational exposure to a known human carcinogen or mutagen (including ionising radiation); or

  (b) any disease attributed to an occupational exposure to a biological agent.

• Details of the work activity that led to the disease:

• Photos

  Media

Mitigation actions

• What action was taken immediately after the incident?

• Has anything been done to prevent a recurrence?

  Yes

  No

• Describe what has been done to prevent a recurrence.

• What do you think should be done to prevent a recurrence?

Witnesses

• Where there any witnesses?

  Yes

  No

Witness Statement

• Statement

• Name and signature

  Sign

• Contact number

• Email

Report sign off

• Once completed, please send this form to the H&S Manager.
  Email: rodrigomelo@abbeypynford.co.uk
  Phone: 07970 916 767

• Name and signature of the person reporting the incident

  Sign