Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Reference number (from the notification e-mail)

  • Incident Summary

Accident report

Incident Category:

  • What is the loss category?

  • Incident definitions

  • What is the accident category?

  • Has this accident, or one similar to it, occurred on site within the last 30 days?

  • This accident requires a level two investigation

Define Problem

  • When was the accident?

  • Where did the accident occour in the facility?

  • What equipment was involved in the accident (include photo)

  • Please describe equipment involved

  • Who was the injured person (please use initials only)

  • What is their employment status?

  • What is their shift pattern?

  • Where on the body was their injury?

  • Where specifically on the left side of the body?

  • all head injuries will require a full investigation

  • Circle the body part affected

  • Where specifically on the right side of the body?

  • all head injuries will require a full investigation

  • Circle the body part affected

  • What was the injury type?

  • Is this occurrence related to a previously known medical condition or injury?

  • Has this person received training in the task where the accident occurred?

  • Provide evidence of training such as certificate or attendance record

  • What level of experience does this person have?

  • Please describe the accident in detail

  • Was PPE required to be worn?

  • Which PPE was required to be worn?

  • Was the correct PPE being worn at the time of the accident?

  • Does CCTV or video footage exist of the accident?

  • Provide link to the footage or still screen shots

  • What was the immediate response?

  • Who was the first aider? (please use initials only)

  • Was treatment permitted?

  • What first aid treatment was applied?

  • Please specify first aid treatment applied

  • What time were the emergency services called?

  • What time did the emergency services arrive?

  • Were any witness statements documented?

  • Please attach the documents

  • Was Violence or Aggression involved?

  • The HR department must be involved

Completion

  • Name of person completing report

Designate Team

  • Team Leader:

  • Team Members:

Define Problem

  • When was the accident?

  • Where did the accident occour in the facility?

  • What equipment was involved in the accident (include photo)

  • Please describe equipment involved

  • Who was the injured person (please use initials only)

  • What is their employment status?

  • What is their shift pattern?

  • Where on the body was their injury?

  • Where specifically on the left side of the body?

  • all head injuries will require a full investigation

  • Circle the body part affected

  • Where specifically on the right side of the body?

  • all head injuries will require a full investigation

  • Circle the body part affected

  • What was the injury type?

  • Is this occurrence related to a previously known medical condition or injury?

  • Has this person received training in the task where the accident occurred?

  • Provide evidence of training such as certificate or attendance record

  • What level of experience does this person have?

  • Please describe the accident in detail

  • Was PPE required to be worn?

  • Which PPE was required to be worn?

  • Was the correct PPE being worn at the time of the accident?

  • Does CCTV or video footage exist of the accident?

  • Provide link to the footage or still screen shots

  • What was the immediate response?

  • Who was the first aider? (please use initials only)

  • Was treatment permitted?

  • What first aid treatment was applied?

  • Please specify first aid treatment applied

  • What time were the emergency services called?

  • What time did the emergency services arrive?

  • Were any witness statements documented?

  • Please attach the documents

  • Was Violence or Aggression involved?

  • The HR department must be involved

  • Level One investigation is required

Designate Team

  • Team Leader:

  • Team Members:
  • Name of team member

Define Problem

  • When was the accident?

  • Where did the accident occour in the facility?

  • What equipment was involved in the accident (include photo)

  • Please describe equipment involved

  • Who was the injured person (please use initials only)

  • What is their employment status?

  • What is their shift pattern?

  • Where on the body was their injury?

  • Where specifically on the left side of the body?

  • all head injuries will require a full investigation

  • Circle the body part affected

  • Where specifically on the right side of the body?

  • all head injuries will require a full investigation

  • Circle the body part affected

  • What was the injury type?

  • Is this occurrence related to a previously known medical condition or injury?

  • Has this person received training in the task where the accident occurred?

  • Provide evidence of training such as certificate or attendance record

  • What level of experience does this person have?

  • Please describe the accident in detail

  • Was PPE required to be worn?

  • Which PPE was required to be worn?

  • Was the correct PPE being worn at the time of the accident?

  • What were the environmental conditions at the time of the accident?

  • Does CCTV or video footage exist of the accident?

  • Provide link to the footage or still screen shots

  • What was the immediate response?

  • Who was the first aider? (please use initials only)

  • Was treatment permitted?

  • What first aid treatment was applied?

  • Please specify first aid treatment applied

  • What time were the emergency services called?

  • What time did the emergency services arrive?

  • Were any witness statements documented?

  • Please attach the documents

  • Was Violence or Aggression involved?

  • The HR department must be involved

  • RIDDOR Category

  • RIDDOR Website England/ Scotland/ Wales: https://www.hse.gov.uk/riddor/report.htm

  • RIDDOR Website Northern Ireland: https://www.hseni.gov.uk/report-incident

  • RADOR Website ROI: https://webapps.hsa.ie/Account/Login?ReturnUrl=%2f

  • RIDDOR / RADOR Reference Number (attach a copy of the report to this pack)

  • Who made the RIDDOR / RADOR report? (print name)

  • This incident does not require an investigation

  • When was the incident?

  • Where did the incident occur in the facility?

  • Who was involved (please use initials only)

  • What is their employment status?

  • Describe the incident

  • What treatment was given?

  • Who was the first aider? (please use initials only)

  • Has their manager been informed?

Sign off

  • Name of person reporting incident

  • Incident definitions

  • What is the environmental incident category?

Investigation Team

  • Team leader

  • Team Members
  • Name of Team member

Define Problem

  • When was the incident.

  • Where did the incident occur

  • What equipment/infrastructure/products/services/scenario involved.

  • What was the cause of the chemical spill

  • Description of the incident in detail

  • What was your immediate response

  • Who was involved (Use initials only)

  • What is their employment status?

  • Has this person received training in the task where the accident occurred?

  • Provide evidence of training such as certificate or attendance record

  • What level of experience does this person have?

  • Please describe the accident in detail

  • Does CCTV or video footage exist of the accident?

  • Provide link to the footage or still screen shots

  • Did anyone witness the event?

  • Was a written witness statement(s) taken from the individuals?

  • Attach witness statement to the report here.

  • What was the cause of the waste issue

  • Who was involved (Use initials only)

  • What was the immediate response.

  • Description of the incident in detail

  • Did anyone witness the incident

  • Was a written statement(s) taken from the individuals?

  • Attach statement(s) here

  • Take statement(s) and attach here

  • What was the cause of the utility issue.

  • Who was involved (Use initials only)

  • What was the immediate response (ADD DETAILED DROPDOWN)

  • Description of the incident in detail

  • Did anyone witness the event.

  • Was a written witness statement(s) taken from the individual

  • Attach statement(s) here.

  • Take statement(s) and attach to the report here.

  • What was the cause of the fire.

  • Description of the incident in detail

  • What was the immediate response.

  • Did anyone witness the event

  • Was a written witness statement(s) taken from the individuals?

  • Attach the witness statement(s) here.

  • Take statement(s) and attach to the report here.

  • What was the cause of the fire.

  • Who was involved (Use initials only).

  • Description of the incident in detail

  • What was the immediate response

  • Did anyone witness the event

  • Was a written witness statement(s) taken from the individual(s)?

  • Take statements from the individual(s) and attach to the report here.

  • Attach the statement(s) to the incident report here.

  • What was the result of the flood or weather event?

  • The line manager is responsible for completing the online form https://www.gov.uk/report-an-environmental-incident (UK) / https://www.epa.ie/ (IRE). Support can be obtained from the QSHE team qshe@dbschenker.com and must inform their senior manager of the accident as soon as possible.

  • Has this incident, or one similar to it, occurred on site within the last 30 days

  • This incident requires a level one investigation

Investigation Team

  • Team leader

  • Team Members
  • Name of Team member

Define Problem

  • When was the incident.

  • Where did the incident occur

  • What equipment/infrastructure/products/services/scenario involved.

  • What was the cause of the chemical spill

  • Description of the incident in detail

  • What was your immediate response

  • Who was involved (Use initials only)

  • What is their employment status?

  • Has this person received training in the task where the accident occurred?

  • Provide evidence of training such as certificate or attendance record

  • What level of experience does this person have?

  • Please describe the accident in detail

  • Does CCTV or video footage exist of the accident?

  • Provide link to the footage or still screen shots

  • Did anyone witness the event?

  • Was a written witness statement(s) taken from the individuals?

  • Attach witness statement to the report here.

  • What was the cause of the waste issue

  • Who was involved (Use initials only)

  • What was the immediate response.

  • Description of the incident in detail

  • Did anyone witness the incident

  • Was a written statement(s) taken from the individuals?

  • Attach statement(s) here

  • Take statement(s) and attach here

  • What was the cause of the utility issue.

  • Who was involved (Use initials only)

  • What was the immediate response (ADD DETAILED DROPDOWN)

  • Description of the incident in detail

  • Did anyone witness the event.

  • Was a written witness statement(s) taken from the individual

  • Attach statement(s) here.

  • Take statement(s) and attach to the report here.

  • What was the cause of the fire.

  • Description of the incident in detail

  • What was the immediate response.

  • Did anyone witness the event

  • Was a written witness statement(s) taken from the individuals?

  • Attach the witness statement(s) here.

  • Take statement(s) and attach to the report here.

  • What was the cause of the fire.

  • Who was involved (Use initials only).

  • Description of the incident in detail

  • What was the immediate response

  • Did anyone witness the event

  • Was a written witness statement(s) taken from the individual(s)?

  • Take statements from the individual(s) and attach to the report here.

  • Attach the statement(s) to the incident report here.

  • What was the result of the flood or weather event?

  • This accident requires a level two investigation

  • When was the accident?

  • Where did the accident occour in the facility?

  • What equipment was involved in the accident (include photo)

  • Please describe equipment involved

  • Who was involved (please use initials only)

  • What is their employment status?

  • Has this person received training in the task where the accident occurred?

  • Provide evidence of training such as certificate or attendance record

  • What level of experience does this person have?

  • Please describe the accident in detail

  • Does CCTV or video footage exist of the accident?

  • Provide link in the notes to the location of the footage or still screen shots

  • What was the immediate response?

  • Who was the first aider? (please use initials only)

  • Were any witness statements documented?

  • Please attach the documents

  • Obtain witness statements from the injured person, first aiders and any witnesses.

  • Does a risk assessment exist for this task?

  • Has the risk assessment been reviewed?

  • The risk assessment must be reviewed before closing this investigation

  • What is the risk assessment reference?

  • A risk assessment must be devised and communicated. Please raise an action to complete an assessment as required in QSHE SOP 006

    risk.JPG
  • For a level 2 investigation we use a simple Ishikawa principle to determine a potential root cause

    fishbone.JPG
  • What was the potential cause of this accident?

  • What corrective actions have been implemented to improve the human factor cause of this accident?

  • Please describe the action implemented

  • Has this action been completed?

  • The investigation can not be closed until the action is completed

  • Provide evidence of the completed action

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the materials used in this accident? (include details in the notes)

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the measurement aspects of this accident? (include details in the notes)

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Describe corrective action implemented

  • Has this action been completed?

  • What corrective actions have been implemented to improve the equipment used in this accident? (include details in the notes)

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Describe the action required to improve the equipment used in the accident

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the process related to this accident? (include details in the notes)

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the environment associated with this accident? (include details in the notes)

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

Completion

  • Name of person completing report

Investigation of Accident

Interim Containment

  • Describe what has been put in place to stop the issue from escalating?

  • What corrective actions have been implemented to improve the human factor cause of this accident?

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the materials used in this accident?

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the measurement aspects of this accident?

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Describe corrective action implemented

  • Has this action been completed?

  • What corrective actions have been implemented to improve the equipment used in this accident?

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Describe the action required to improve the equipment used in the accident

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the process related to this accident?

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • What corrective actions have been implemented to improve the environment associated with this accident?

  • Please describe the action implemented

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

  • Has this action been completed?

Verify and Determine the root cause

  • You can use the simple Ishikawa principle to determine a potential root cause as a brain storming tool with the colleagues or the 5 Why process

    Screenshot 2022-03-09 at 15.01.40.png
  • Which root cause analysis will you use?

  • 5 Why Analysis (click the green + button to complete)
  • What is the problem you are going to root cause analyse

  • Why?

  • Why?

  • Why?

  • Why?

  • Why?

  • As determined by the 5Why above, what are the Immediate/Direct Causes (circumstances that immediately precede the accident)

  • As determined by the 5Why above, what is the Basic/Root Cause for the accident?

  • What was the Person/ Human Factor Root cause?

  • What is the job/ system factor of the root cause

Define and implement Corrective Actions (e.g what actions can be taken to rectify the root casues identified in section 4)

  • Include a Actions and assign a SMART objective

Verify Permanent Corrections (PCs) for Problem

  • Can the issue be recreated by removing one or more of the results identified in section 5?

  • Can the problem be corrected again by reinstating the results identified above?

Prevent Recurrence

  • Has the problem has reoccurred since implementation of all actions.

  • The root cause analysis should be reviewed and additional prevenatative actions implemented

  • Does a risk assessment exist for this task?

  • Has the risk assessment been reviewed?

  • The risk assessment must be reviewed before closing this investigation

  • What is the risk assessment reference?

  • A risk assessment must be devised and communicated. Please raise an action to complete an assessment as required in QSHE SOP 006

    risk.JPG
  • Has the procedure/ process been updated?

  • Have the results and improvements been communicated to all affected persons?

  • Has the corrective action been witnessed?

  • If the answer is yes to all of the above in this section, then the investigation is ready to be closed

Sign off

End of Investigation - Sign off

  • What time was lost due to the accident (mins/ hours/ days)?

  • Team Leader sign off:

  • First Aider sign off:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.