Cooper Tire & Rubber

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Investigation Team Members

Identification of Incident

• Date and Time incident took place

  Date

• Date and Time Incident reported

  Date

• Incident Reported By

• Where exactly did the incident take place

• Type of Accident

  Select Slip Trip Fall Fall from Height Struck by falling or moving object Collision with fixed object Asphyxia manual Handling injury Violence

  • Slip Trip Fall
  • Fall from Height
  • Struck by falling or moving object
  • Collision with fixed object
  • Asphyxia
  • manual Handling injury
  • Violence

• Result of accident / action

  No injury

  First Aid administered

  Medical attention Dr Seen

  Sent or Taken to Hospital

  Fatal

• Has this incident resulted in an employee being off work?

  Yes

  No

• If Incident resulted in employee being off work, how long have they been off?

  1 Day

  Up to 3 days

  3 - 6 Days

  7 Days or more

Incident description

• Describe in detail, how the incident occurred.

• Relevant evidential photos

  Media

• Diagram of incident location

  Drawing

• Was the person or persons involved permitted to be carrying out the tasks

  Yes

  No

  N/A

• Was the person or persons involved, trained on how to carry out the task

  Yes

  No

  N/A

• Photo of Training Docs

  Media

• Describe what equipment was involved EG: Step Ladders, Shelving, Tools etc

• Was the equipment being used, suitable for purpose. Has it been checked.

  Yes

  No

  N/A

• If equipment was found to be unsuitable, what faults were identified and describe what action has been taken.

• Photo of equipment being used during the incident.

  Media

Injured Person(s)

• How many people have been injured

  1

  2

  3

• Name, Address,Date of Birth and Contact details of injured person 1

• In what capacity was the injured person on your premises

  Staff Member

  Customer

  Contractor

  Visitor

  Other

• Describe injuries Sustained as a result of this incident

• Severity of injuries sustained

  No Injury (Near Miss)

  Minor

  Medium

  Severe

• Name, Address,Date of Birth and Contact details of injured person 2

• In what capacity was the injured person on your premises

  Staff Member

  Customer

  Contractor

  Visitor

  Other

• Describe injuries Sustained as a result of this incident

• Severity of injuries sustained

  No Injury (Near Miss)

  Minor

  Medium

  Severe

• Name, Address,Date of Birth and Contact details of injured person 3

• In what capacity was the injured person on your premises

  Staff Member

  Customer

  Contractor

  Visitor

  Other

• Describe injuries Sustained as a result of this incident

• Severity of injuries sustained

  No Injury (Near Miss)

  Minor

  Medium

  Severe

Cause of incident

• What do you believe to be the root cause 1 of the incident

  Select Human Error Equipment Failure Design Issues Lack of Training Communication Break Down Lack of Management Control Malicious

  • Human Error
  • Equipment Failure
  • Design Issues
  • Lack of Training
  • Communication Break Down
  • Lack of Management Control
  • Malicious

• What do you believe to be the root cause 2 of the incident

  Select Human Error Equipment Failure Design Issues Lack of Training Communication Break Down Lack of Management Control Malicious

  • Human Error
  • Equipment Failure
  • Design Issues
  • Lack of Training
  • Communication Break Down
  • Lack of Management Control
  • Malicious

• What do you believe to be the root cause 3 of the incident

  Select Human Error Equipment Failure Design Issues Lack of Training Communication Break Down Lack of Management Control Malicious

  • Human Error
  • Equipment Failure
  • Design Issues
  • Lack of Training
  • Communication Break Down
  • Lack of Management Control
  • Malicious

• Explain your reasons / evidence to support the causation theory.

• Could this incident have been avoided. Was it foreseeable

  Yes

  No

  N/A

Recommendation for additional Control Measures

• What are your recommendations to prevent re-occurrence. Describe additional control measures required or relevant action required.

• Have control measures been implemented

  Yes

  No

  N/A

• How would you now rate the hazard status, following your implemented control measures

  Safe

  At Risk

  N/A

Enforcement Authorities & Action

• Has the incident been reported under RIDDOR

  Yes

  No

  N/A

• Name and Contact Details of EHO (Environmental Health Officer)

• Name and Contact Details of Fire Safety Officer

• What type of enforcement action is being taken.

  NFA (Advice Only)

  Improvement Notice

  Prohibition Notice

  Closure Notice

  Prosecution Notice.

Investigation Summary

• Investigation Team Members

• Investigation Report Completed By:
  Tim White, MS, NREMT-P
  Health & Safety Manager

• Investigation Completed by

  Sign

• Position

  Select Group Security Manager RLPM LPO HR Manager Area Manager Store Manager Assistant Store Manager Floor Manager

  • Group Security Manager
  • RLPM
  • LPO
  • HR Manager
  • Area Manager
  • Store Manager
  • Assistant Store Manager
  • Floor Manager

• Other persons involved in investigation process / Site Manager

  Sign

• Position

  Select Group Security Manager RLPM LPO HR Manager Area Manager Store Manager Assistant Store Manager Floor Manager

  • Group Security Manager
  • RLPM
  • LPO
  • HR Manager
  • Area Manager
  • Store Manager
  • Assistant Store Manager
  • Floor Manager