BCC

• BCC

• Conducted on

  Date
• Location
  Address

• Prepared by

Type of Accident/Incident and Persons Involved

• Type of accident/incident

  Select First Aid Injury Incident Property Damage Lost Time Fatality

  • First Aid
  • Injury
  • Incident
  • Property Damage
  • Lost Time
  • Fatality

• Employee Name & job title

• Site & location

• Length of employment

• Length of time on current job

• Supervisor

• Senior PM

• General superintendent

• Select date

  Date

Accident/Incident Details

• Nature of injury, body parts affected (if applicable)

• Name and phone number of doctor or clinic (if applicable)
  Address

• Damages to material or equipment? (Make, model, equipment number) and extent of damages (estimated repair costs)

• Disciplinary action if any

• Accident details

• Witnesses

ROOT CAUSE ANALYSIS

• Unsafe acts:

• Unsafe conditions

• Corrective measures taken or needed to prevent this type of accident from reoccurring

Accident site questionnaire

• Was the employee certified to operate this equipment?

  Yes

  No

  N/A

• Was JSA conducted addressing this activity?

  Yes

  No

  N/A

• Was pre-shift inspection conducted of the job site and hazards/changing conditions addressed?

  Yes

  No

  N/A

• Was employee statement taken?

  Yes

  No

  N/A

• Were any witness statements taken?

  Yes

  No

  N/A

• Was employee instructed to perform the task by a supervisor?

  Yes

  No

  N/A

• Who was the supervisor?

• Were there any photos taken?

  Yes

  No

  N/A

• Accident site layout, additional details

  Drawing

• Accident site photo

  Media

• Person taking photos Name

• Who provided information for this report?

  Yes

  No

  N/A

• Name or names of persons providing information for this report?

• Were there any special conditions present?

  Yes

  No

  N/A

• If so, what special conditions were present?

• Additional details

Accident investigation performed by

• Supervisor

  Sign

• Select date

  Date

• Site safety manager

  Sign

• Select date

  Date

• Reviewed by project manager

  Sign

• Select date

  Date

• Reviewed by corporate safety director

  Sign

• Select date

  Date