Crawley Borough Council Incident Investigation

• Document No.

• Audit Title

• Client / Site

• Image of site

  Media

• Investigation Started on

  Date

• Prepared by

Executive summary

• Background

• Conclusions drawn

• cost to the organisation

• Recommendations

• Method of investigation

Part 1 - to be completed immediately upon notification

• Initial report made by

• Date of incident if known

  Date

• Time of incident if known

  Date

• Incident

• Ill health

• Minor injury

• Serious injury

• Fatality

• Near miss

• Number of casualties

• Date initial report was received by corporate and public safety

  Date

• Tap to enter information

  Off

  On

Part 2 initial assessment be carried out by the person responsible for health and safety

• Types of incident

  Select Accident Ill health Near miss Undesirable circumstance

  • Accident
  • Ill health
  • Near miss
  • Undesirable circumstance

• Potential for harm

  Select Fatal Major or multiple serious injuries Serious injuries Minor injuries Damage only Reputation

  • Fatal
  • Major or multiple serious injuries
  • Serious injuries
  • Minor injuries
  • Damage only
  • Reputation

• Is the incident reportable under RIDDOR

  No

  Yes

  N/A
Tap to enter information

• Date and time reported and report number

• Copy of report

  Media

• Incident report completed ? Date entered / reference number

  Yes

  No

  N/A

• Level of investigation carried out by line manager

  In depth

  Adequate

  Cursory

  Non existent

• Name of line manager?

• Is a further investigation required?

• Priority of investigation? ( 1 is low 5 is high)

• Names of people required during the further investigation

Part 3 investigation and information gathering

• 1. Where did the incident take place
  Address

• Site photo

  Media

• 2. Names of the injured person and extent of injuries or ill health including the type and location of any injury

• 3. Brief description of how the incident occurred

• 4. What work activities would be carried out at the time?

• 5. Was there anything unusual about the work conditions at the time?

  Yes

  No

  N/A

• 6. Is there a risk assessment available for the activity?

  Yes

  No

  N/A

• 7. Is there an adequate safe working procedure available?( or method statement)

  Yes

  No

  N/A
Tap to enter information

• 7a. Was it followed?

  Yes

  No

  N/A
Tap to enter information

• 7a. Why not?

• 8. Was the risk known ?

  Yes

  No

  N/A
Tap to enter information

• 8a. Why was it not controlled?

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• 8a. Why was the risk not foreseen

• 9. Did the organisation and arrangement of the work influence the adverse effect?

  Yes

  No

  N/A

• 10. Was maintenance and cleaning sufficient?

  Yes

  No

  N/A

• 11. Weather people involved to be considered a competent and suitable?

  Yes

  No

  N/A

• 12. Did the workplace layout influence the adverse event?

  Yes

  No

  N/A

• 13. Did the nature or shape of the materials or substance influence the adverse event?

  Yes

  No

  N/A

• 14. Did any machinery or equipment influence the adverse effect?

  Yes

  No

  N/A

• 15. Was safety equipment sufficient?

  Yes

  No

  N/A

• 16. Was PPE required?

  No

  Yes

  N/A
Tap to enter information

• 16a. Was it issued?

  Yes

  No

  N/A

• 16b. Was it warm and used correctly?

  Yes

  No

  N/A

• 17. did other conditions influence the adverse event?

  Yes

  No

  N/A

Part 3a evidence and statements

Physical evidence

• Has any physical evidence been seized or recovered?
Tap to enter information Physical evidence

• Description of evidence seized or recovered

• Photographs of evidence seized or recovered

  Media

• Have any witness statements been taken?
Tap to enter information Witness statements

• Name of witness

• Date statement received

  Date

• Notes

• Statement

  Media

• Other previously not included photographic or document evidence

  Media

Part 4 legislation and legal risks

Legislation

• Tap to enter information

  Select Health and safety at work act Management of health and safety at work regulations Reporting of injuries diseases & dangerous occurrences regulations Workplace health safety and welfare regulations First aid at work regulations Electricity at work regulations Safety signs and signals regulations Control of asbestos regulations Control of noise at work regulations Lifting operations and lifting equipment regulations Provision and use of work equipment regulations Construction design and maintenance regulations Gas safety( management) regulations Working at height regulations Manual handling regulations Personal protective equipment regulations Control of substances hazardous to health regulations Display screen equipment regulations Control of vibration at work regulations Control of legionella bacteria in the workplace Confined space regulations Dangerous substances and explosive atmospheres regulations Regulator re reform (fire safety) order Pressure systems safety regulations other

  • Health and safety at work act
  • Management of health and safety at work regulations
  • Reporting of injuries diseases & dangerous occurrences regulations
  • Workplace health safety and welfare regulations
  • First aid at work regulations
  • Electricity at work regulations
  • Safety signs and signals regulations
  • Control of asbestos regulations
  • Control of noise at work regulations
  • Lifting operations and lifting equipment regulations
  • Provision and use of work equipment regulations
  • Construction design and maintenance regulations
  • Gas safety( management) regulations
  • Working at height regulations
  • Manual handling regulations
  • Personal protective equipment regulations
  • Control of substances hazardous to health regulations
  • Display screen equipment regulations
  • Control of vibration at work regulations
  • Control of legionella bacteria in the workplace
  • Confined space regulations
  • Dangerous substances and explosive atmospheres regulations
  • Regulator re reform (fire safety) order
  • Pressure systems safety regulations
  • other

• Detail

• Could this have been breached?
Other risks to the council and its officers

• Description and nature of the risk including maximum penalty if applicable

• Is this risk to council officers or the corporate body

Part 5 analysis

Current controls

• Current control measures in place and was it followed?

• Root cause analysis diagram

  Media

• Immediate cause

• Underlying causes

• Root causes

• Are there similar risks elsewhere?

  Safe

  At Risk

  N/A

• Have similar incident happened before?

  Yes

  No

  N/A

• cost of this incident to the organisation

• Total cost of this incident so far

Tap to enter information

Part 6 - recommendations

• Does the risk assessment require amending?

  No

  Yes

  N/A
Tap to enter information

• Name of responsible officer

• Target date

  Date

• Does any method statement require amendment

  No

  Yes

  N/A
Tap to enter information

• Name of responsible officer

• Target date

  Date

Other recommendations

Controls

• Control measure or recommendation

• Target date

  Date

• Controls
  description
  responsible person

Part 7 end of report

• Signed on behalf of the investigation team

  Sign

• Position

• Members of the investigation team

• Distribution List name and position

• List of appendices