DATJ 120 Incident and investigation form

• Site conducted

  Select

• Business unit

  Select

• Prepared by

• Reference number

• Category of Injury/Loss

  Select Potential Cluster of Potential incidents Minor Major Significant Colleague illness (not work related accident)

  • Potential
  • Cluster of Potential incidents
  • Minor
  • Major
  • Significant
  • Colleague illness (not work related accident)

• Incident Summary

• When was the incident? (Date incident occurred not the reporting date).

  Date

• 

Incident Category:

• What is the loss category?

  Quality

  Health & Safety

  Environment

  Security

• Incident definitions as describes in QSHE SOP 041

  

• What is the accident category?

  Select Potential Cluster of Potential incidents Minor Major Significant Colleague illness (not work related accident)

  • Potential
  • Cluster of Potential incidents
  • Minor
  • Major
  • Significant
  • Colleague illness (not work related accident)

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

  Yes

  No

• This accident requires a level two investigation

• Where did the accident occur in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

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

  Select Blade/ Knife Compactors Contractor owned equipment Customer Property - Damaged upon receipt Customer Property - Damaged within the facility Dangerous Goods Item Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, skates, hooks etc) MHE ( FLT, PPR, Wave, Turret etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck (Contractor owned) Road Van/Truck (DBS owned) Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Customer Property - Damaged upon receipt
  • Customer Property - Damaged within the facility
  • Dangerous Goods Item
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, skates, hooks etc)
  • MHE ( FLT, PPR, Wave, Turret etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck (Contractor owned)
  • Road Van/Truck (DBS owned)
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Who was involved (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

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

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

• What was the immediate response?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Ambulance required Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Ambulance required
  • Communication to effected parties

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

• Did anyone witness the event?

  Yes

  No

• Obtain and attach the witness statement

• Does a risk assessment exist for this task?

  Yes

  No

• Has the risk assessment been reviewed?

  Yes

  No

• 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

  

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

  

• What was the potential cause of this accident?

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

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

  Select Lessons Learnt communicated Re-training Other

  • Lessons Learnt communicated
  • Re-training
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

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

• Provide evidence of the completed action

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

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

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Completion

• Name of person completing report

  Sign

• This accident requires a Level One investigation (see QSHE SOP 045)

  

1D – Designate Team

• Team Leader:

• Team Members:

2D – Define Problem

• When was the accident?

  Date

• Where did the accident occour in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

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

  Select Blade/ Knife Compactors Contractor owned equipment Customer Property - Damaged upon receipt Customer Property - Damaged within the facility Dangerous Goods Item Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, skates, hooks etc) MHE ( FLT, PPR, Wave, Turret etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck (Contractor owned) Road Van/Truck (DBS owned) Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Customer Property - Damaged upon receipt
  • Customer Property - Damaged within the facility
  • Dangerous Goods Item
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, skates, hooks etc)
  • MHE ( FLT, PPR, Wave, Turret etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck (Contractor owned)
  • Road Van/Truck (DBS owned)
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Who was involved (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

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

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does the person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

• Provide link to the footage or still screen shots

• What was the immediate response?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Ambulance required Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Ambulance required
  • Communication to effected parties

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

• Were any witness statements documented?

  Yes

  No

• Please attach the documents

3D Interim Containment

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

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

• What has been put in place to stop the issue from escalating with respect to human factors ?

  Select Person removed from task Suspension Other

  • Person removed from task
  • Suspension
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Please describe the action taken

• Has this action been completed?

  Yes

  No

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

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

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

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

4D Verify and Determine the root cause

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)

  Select Acts/ Practices Conditions

  • Acts/ Practices
  • Conditions

• Detail the act or practice that is the immediate root cause

• Detail the condition that is the root cause

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

  Select Personal/ Human Factors Job/ System Factors

  • Personal/ Human Factors
  • Job/ System Factors

• What was the Person/ Human Factor Root cause?

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

5D: 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

6D: Verify Permanent Corrections (PCs) for Problem

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

  Yes

  No

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

  Yes

  No

7D: Prevent Recurrence

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

  yes

  no

• Does a risk assessment exist for this task?

  Yes

  No

• Has the risk assessment been reviewed?

  Yes

  No

• 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

  

• Has the procedure/ process been updated?

  Yes

  No

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

  Yes

  No

• Has the corrective action been witnessed?

  Yes

  No

• If the answer is yes to all of the above then the 8D investigation is ready to be closed

8D: Congratulate Your Team

• Team Leader sign off:

  Sign

• Completion Date

  Date

• Level One investigation is required (see QSHE SOP 045)

  

Designate Team

• Team Leader:

• Team Members:

Define Problem

• Where did the accident occour in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

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

  Select Blade/ Knife Compactors Contractor owned equipment Customer Property - Damaged upon receipt Customer Property - Damaged within the facility Dangerous Goods Item Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, skates, hooks etc) MHE ( FLT, PPR, Wave, Turret etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck (Contractor owned) Road Van/Truck (DBS owned) Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Customer Property - Damaged upon receipt
  • Customer Property - Damaged within the facility
  • Dangerous Goods Item
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, skates, hooks etc)
  • MHE ( FLT, PPR, Wave, Turret etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck (Contractor owned)
  • Road Van/Truck (DBS owned)
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Who was involved (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

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

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

• What was the immediate response?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Ambulance required Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Ambulance required
  • Communication to effected parties

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

• Were any witness statements documented?

  Yes

  No

• Please attach the documents

Interim Containment

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

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

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

  Select Lessons Learnt communicated Re-training Other

  • Lessons Learnt communicated
  • Re-training
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

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

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Verify and Determine the root cause

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)

  Select Acts/ Practices Conditions

  • Acts/ Practices
  • Conditions

• Detail the act or practice that is the immediate root cause

• Detail the condition that is the root cause

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

  Select Personal/ Human Factors Job/ System Factors

  • Personal/ Human Factors
  • Job/ System Factors

• 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?

  Yes

  No

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

  Yes

  No

Prevent Recurrence

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

  yes

  no

• Does a risk assessment exist for this task?

  Yes

  No

• Has the risk assessment been reviewed?

  Yes

  No

• 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

  

• Has the procedure/ process been updated?

  Yes

  No

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

  Yes

  No

• Has the corrective action been witnessed?

  Yes

  No

• If the answer is yes to all of the above then the 8D investigation is ready to be closed

8D: Congratulate Your Team

• Team Leader sign off:

  Sign

• Completion Date

  Date

• The line manager is responsible for completing the online form RIDDOR (UK) / Reporting of an accident to HSA (IRE). Support can be obtained from the QSHE team qshe@dbshenker.com and must inform their senior manager of the accident as soon as possible.

• This accident requires a level two investigation

• When was the first potential reported ?

  Date

• When was the latest potential reported ?

  Date

• How many potentials of similar nature have been reported during this time?

• Where did the potentials occur in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

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

  Select Blade/ Knife Compactors Contractor owned equipment Customer Property - Damaged upon receipt Customer Property - Damaged within the facility Dangerous Goods Item Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, skates, hooks etc) MHE ( FLT, PPR, Wave, Turret etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck (Contractor owned) Road Van/Truck (DBS owned) Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Customer Property - Damaged upon receipt
  • Customer Property - Damaged within the facility
  • Dangerous Goods Item
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, skates, hooks etc)
  • MHE ( FLT, PPR, Wave, Turret etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck (Contractor owned)
  • Road Van/Truck (DBS owned)
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Who was involved (please use initials only)

• Please describe the cluster of potentials in detail

• What was the immediate response?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Ambulance required Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Ambulance required
  • Communication to effected parties

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

• Were any witness statements documented?

  Yes

  No

• Please attach the documents

• Does a risk assessment exist for this task?

  Yes

  No

• Has the risk assessment been reviewed?

  Yes

  No

• 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

  

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

  

• What was the potential cause of this accident?

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

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

  Select Lessons Learnt communicated Re-training Other

  • Lessons Learnt communicated
  • Re-training
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

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

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Completion

• Name of person completing report

  Sign

• Where did the potential occur in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

• What occurred.

• What equipment was involved in the potential incident ?

  Select Blade/ Knife Compactors Contractor owned equipment Customer Property - Damaged upon receipt Customer Property - Damaged within the facility Dangerous Goods Item Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, skates, hooks etc) MHE ( FLT, PPR, Wave, Turret etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck (Contractor owned) Road Van/Truck (DBS owned) Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Customer Property - Damaged upon receipt
  • Customer Property - Damaged within the facility
  • Dangerous Goods Item
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, skates, hooks etc)
  • MHE ( FLT, PPR, Wave, Turret etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck (Contractor owned)
  • Road Van/Truck (DBS owned)
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Has an action been completed to avoid the potential incident escalating into an accident?

  Yes

  No

Completion

• Name of person completing report

  Sign

• This incident does not require an investigation

• When was the incident or when the illness was 1st reported/notified?

  Date

• Where did the incident occur in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

• Who was involved (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

• Describe the incident

• What treatment was given?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Ambulance required Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Ambulance required
  • Communication to effected parties

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

• Has their manager been informed?

  Yes

  No

Sign off

• Name of person reporting incident

  Sign

• Incident definitions as described in QSHE SOP 041.

  

• What is the environmental incident category?

  Select Potential Cluster of Potential incidents Minor Major Significant Colleague illness (not work related accident)

  • Potential
  • Cluster of Potential incidents
  • Minor
  • Major
  • Significant
  • Colleague illness (not work related accident)

Investigation Team

• Team leader

Team Members

• Name of Team member

Define Problem

• Where did the incident occur

  Select Warehouse Office Yard Offsite Whole Facility

  • Warehouse
  • Office
  • Yard
  • Offsite
  • Whole Facility

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

  Chemical Spill

  Waste Management

  Utilities

  Fire

  Flood and Weather

• What was the cause of the chemical spill

  Select Loss of vehicle fuel containment Damaged chemical container Incorrect use of chemical During decanting process

  • Loss of vehicle fuel containment
  • Damaged chemical container
  • Incorrect use of chemical
  • During decanting process

• Description of the incident in detail

• What was your immediate response

  Select Access to site checked/made secure Air Con/heating switched off/windows closed. Alarm Raised (External) Alarm Raised (Internal System) Absorbent socks used to prevent spread Area cleared of excess water Area cleared of litter/dirt Bin/Skip covered/sealed Building Evacuated Customer stock removed from the area. Drains blocked with drain covers Doors closed in warehouse/temperature controlled areas. Equipment and machinery removed from the area. Equipment serviced/calibrated. Fire fighting/suppression equipment ordered/distributed. Fire tackled Leak plugged/sealed Leaking drum/vessel placed on bunded pallet Main site shut off taps closed. Nothing Spill kit and/or consumables ordered/distributed. Storage/spill bund drained of water. Storage/spill bund protected against weather Unused electrical devices turned off. Waste removed and placed in correct bins/skips Waste stored elsewhere (Temporary) Water outlets turned off Weeping/dripping valves/pipes repaired. Other

  • Access to site checked/made secure
  • Air Con/heating switched off/windows closed.
  • Alarm Raised (External)
  • Alarm Raised (Internal System)
  • Absorbent socks used to prevent spread
  • Area cleared of excess water
  • Area cleared of litter/dirt
  • Bin/Skip covered/sealed
  • Building Evacuated
  • Customer stock removed from the area.
  • Drains blocked with drain covers
  • Doors closed in warehouse/temperature controlled areas.
  • Equipment and machinery removed from the area.
  • Equipment serviced/calibrated.
  • Fire fighting/suppression equipment ordered/distributed.
  • Fire tackled
  • Leak plugged/sealed
  • Leaking drum/vessel placed on bunded pallet
  • Main site shut off taps closed.
  • Nothing
  • Spill kit and/or consumables ordered/distributed.
  • Storage/spill bund drained of water.
  • Storage/spill bund protected against weather
  • Unused electrical devices turned off.
  • Waste removed and placed in correct bins/skips
  • Waste stored elsewhere (Temporary)
  • Water outlets turned off
  • Weeping/dripping valves/pipes repaired.
  • Other

• Who was involved (Use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

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

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

• Provide link to the footage or still screen shots

• Did anyone witness the event?

  Yes

  No

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

  Yes

  No

• Attach witness statement to the report here.

• What was the cause of the waste issue

  Waste placed in wrong bin/skip

  Waste spilling from bin/skip

  Fly tipping

• Who was involved (Use initials only)

• What was the immediate response.

  Spare

• Description of the incident in detail

• Did anyone witness the incident

  Yes

  No

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

  Yes

  No

• Attach statement(s) here

  Confirmed

• Take statement(s) and attach here

  Confirmed

• What was the cause of the utility issue.

  Select Combination of gas heating, air conditioning or open doors/windows working against each other. Electrical machinery/devices left on for excessive periods/overnight when not in use. Gas heating systems left on or not moved to tick-over mode when office unoccupied during the evening/weekend. Warehouse heating/temperature control systems left on with doors/shutters left open. Water outlets for cleaning, vehicle washing or welfare left running unnecessarily. Fluid/Fuel leak of a vehicle/plant/tank (3rd party owned) Fluid/Fuel leak of a vehicle/plant/tank (DBS Owned) Leak from customer owned goods Drainage system failure Gutting overflowing Office flooded - Unable to operate Office flooded - Able to operate but with distruptions Roof leaking Weather damage to doors, gates, roof walls and/or windows Yard flooded - Unable to operate Yard flooded - Able to operate but with disruptions. Arson/deliberate act. Carelessness by individual (E.g. discarded smoking materials). Electrical fault (fixed wiring) Issues during repairs/modifications to equipment/facility (3rd Party Contractors) Reactions from hazardous materials Stand alone office/warehouse devices creating fumes, overheating or smoking. Electrical fault (cables/equipment). Extreme wet/windy weather/storm Burst Pipes Taps/water outlets left running

  • Combination of gas heating, air conditioning or open doors/windows working against each other.
  • Electrical machinery/devices left on for excessive periods/overnight when not in use.
  • Gas heating systems left on or not moved to tick-over mode when office unoccupied during the evening/weekend.
  • Warehouse heating/temperature control systems left on with doors/shutters left open.
  • Water outlets for cleaning, vehicle washing or welfare left running unnecessarily.
  • Fluid/Fuel leak of a vehicle/plant/tank (3rd party owned)
  • Fluid/Fuel leak of a vehicle/plant/tank (DBS Owned)
  • Leak from customer owned goods
  • Drainage system failure
  • Gutting overflowing
  • Office flooded - Unable to operate
  • Office flooded - Able to operate but with distruptions
  • Roof leaking
  • Weather damage to doors, gates, roof walls and/or windows
  • Yard flooded - Unable to operate
  • Yard flooded - Able to operate but with disruptions.
  • Arson/deliberate act.
  • Carelessness by individual (E.g. discarded smoking materials).
  • Electrical fault (fixed wiring)
  • Issues during repairs/modifications to equipment/facility (3rd Party Contractors)
  • Reactions from hazardous materials
  • Stand alone office/warehouse devices creating fumes, overheating or smoking.
  • Electrical fault (cables/equipment).
  • Extreme wet/windy weather/storm
  • Burst Pipes
  • Taps/water outlets left running

• Who was involved (Use initials only)

• What was the immediate response (ADD DETAILED DROPDOWN)

  Spare

• Description of the incident in detail

• Did anyone witness the event.

  Yes

  No

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

  Yes

  No

• Attach statement(s) here.

  Confirmed

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

  Confirmed

• What was the cause of the fire.

  Spare

• Description of the incident in detail

• What was the immediate response.

  Spare

• Did anyone witness the event

  Yes

  No

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

  Yes

  No

• Attach the witness statement(s) here.

  Confirmed

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

  Confirmed

• What was the cause of the fire.

  Spare

• Who was involved (Use initials only).

• Description of the incident in detail

• What was the immediate response

  Spare

• Did anyone witness the event

  Yes

  No

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

  Yes

  No

  N/A

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

  Confirmed

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

  Confirmed

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

  Spare

Initial Containment

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

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

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

  Select Lessons Learnt communicated Re-training Other

  • Lessons Learnt communicated
  • Re-training
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

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

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Root cause analysis

• 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

  

• Which root cause analysis will you use?

  Select 5 Why Ishikawa Other

  • 5 Why
  • Ishikawa
  • Other
5 Why Analysis (click on the green + button to add analysis)

• What is the problem you are going to root cause analyse

• Why?

• Why?

• Why?

• Why?

• Why?

• Include evidence of your Ishikawa

• Which root cause analysis tool did you use? (provide evidence of methodology)

• What was determined as the root cause of this accident?

• Include your actions to prevent the action from reoccurring

Verification of corrective actions

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

  Yes

  No

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

  Yes

  No

Prevent Recurrence

• The problem has reoccurred since implementation of all actions.

  yes

  no

• Has the procedure/ risk assessment/ process been updated?

  Yes

  No

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

  Yes

  No

• Has the corrective action been witnessed?

  Yes

  No

Sign off

• Has the QSHE been contacted to inform them of the closure of the investigation?

  Yes

  No

• Provide evidence that the QSHE has been contacted

• Include an action to contact QSHE

• Team Leader sign off:

  Sign

• Completion Date

  Date

• Yes

  No

  N/A

• Yes

  No

  N/A

• 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.

• Where did the potential occur in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

• What occurred?

• What equipment was involved in the potential incident ?

  Select Blade/ Knife Compactors Contractor owned equipment Customer Property - Damaged upon receipt Customer Property - Damaged within the facility Dangerous Goods Item Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, skates, hooks etc) MHE ( FLT, PPR, Wave, Turret etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck (Contractor owned) Road Van/Truck (DBS owned) Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Customer Property - Damaged upon receipt
  • Customer Property - Damaged within the facility
  • Dangerous Goods Item
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, skates, hooks etc)
  • MHE ( FLT, PPR, Wave, Turret etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck (Contractor owned)
  • Road Van/Truck (DBS owned)
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Has an action been completed to avoid the potential incident escalating into an environmental incident?

  Yes

  No

Completion

• Name of person completing report

  Sign

• When was the first potential reported?

  Date

• When was the latest potential reported?

  Date

• How many potentials of similar nature have been reported during this time?

  Date

• Where did the potentials occur in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

• What equipment was involved in the potentials (Include Photo).

  Select Blade/ Knife Compactors Contractor owned equipment Customer Property - Damaged upon receipt Customer Property - Damaged within the facility Dangerous Goods Item Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, skates, hooks etc) MHE ( FLT, PPR, Wave, Turret etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck (Contractor owned) Road Van/Truck (DBS owned) Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Customer Property - Damaged upon receipt
  • Customer Property - Damaged within the facility
  • Dangerous Goods Item
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, skates, hooks etc)
  • MHE ( FLT, PPR, Wave, Turret etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck (Contractor owned)
  • Road Van/Truck (DBS owned)
  • Roller Shutter door
  • Waste

• Has the equipment received a service/thorough examination in the last 12months?

  Yes

  No

• Who was involved (Use initial only)

• Please describe the cluster of potentials in detail

• What was the immediate reponse?

  Spare

• Was any witness statements documented?

  Yes

  No

• Does a risk assessment exist for this task

  Yes

  No

• Following the incidents, has the risk assessment been reviewed.

  Yes

  No

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

  

• What was the potential cause of this environmental incident?

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

• What corrective actions have been implemented to improve the environment associated with this incident.

  Improved waste management

  Additional spill equipment

  Controlled work area

  Other

• Please provide more detail of the corrective action.

• Name of person completing report.

  Sign

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

  Yes

  No

• This incident requires a level one investigation (see QSHE SOP 045)"

  

Investigation Team

• Team leader

Team Members

• Name of Team member

Define Problem

• When was the incident.

  Date

• Where did the incident occur

  Select Warehouse Office Yard Offsite Whole Facility

  • Warehouse
  • Office
  • Yard
  • Offsite
  • Whole Facility

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

  Chemical Spill

  Waste Management

  Utilities

  Fire

  Flood and Weather

• What was the cause of the chemical spill

  Select Loss of vehicle fuel containment Damaged chemical container Incorrect use of chemical During decanting process

  • Loss of vehicle fuel containment
  • Damaged chemical container
  • Incorrect use of chemical
  • During decanting process

• Description of the incident in detail

• What was your immediate response

  Select Access to site checked/made secure Air Con/heating switched off/windows closed. Alarm Raised (External) Alarm Raised (Internal System) Absorbent socks used to prevent spread Area cleared of excess water Area cleared of litter/dirt Bin/Skip covered/sealed Building Evacuated Customer stock removed from the area. Drains blocked with drain covers Doors closed in warehouse/temperature controlled areas. Equipment and machinery removed from the area. Equipment serviced/calibrated. Fire fighting/suppression equipment ordered/distributed. Fire tackled Leak plugged/sealed Leaking drum/vessel placed on bunded pallet Main site shut off taps closed. Nothing Spill kit and/or consumables ordered/distributed. Storage/spill bund drained of water. Storage/spill bund protected against weather Unused electrical devices turned off. Waste removed and placed in correct bins/skips Waste stored elsewhere (Temporary) Water outlets turned off Weeping/dripping valves/pipes repaired. Other

  • Access to site checked/made secure
  • Air Con/heating switched off/windows closed.
  • Alarm Raised (External)
  • Alarm Raised (Internal System)
  • Absorbent socks used to prevent spread
  • Area cleared of excess water
  • Area cleared of litter/dirt
  • Bin/Skip covered/sealed
  • Building Evacuated
  • Customer stock removed from the area.
  • Drains blocked with drain covers
  • Doors closed in warehouse/temperature controlled areas.
  • Equipment and machinery removed from the area.
  • Equipment serviced/calibrated.
  • Fire fighting/suppression equipment ordered/distributed.
  • Fire tackled
  • Leak plugged/sealed
  • Leaking drum/vessel placed on bunded pallet
  • Main site shut off taps closed.
  • Nothing
  • Spill kit and/or consumables ordered/distributed.
  • Storage/spill bund drained of water.
  • Storage/spill bund protected against weather
  • Unused electrical devices turned off.
  • Waste removed and placed in correct bins/skips
  • Waste stored elsewhere (Temporary)
  • Water outlets turned off
  • Weeping/dripping valves/pipes repaired.
  • Other

• Who was involved (Use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

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

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

• Provide link to the footage or still screen shots

• Did anyone witness the event?

  Yes

  No

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

  Yes

  No

• Attach witness statement to the report here.

• What was the cause of the waste issue

  Waste placed in wrong bin/skip

  Waste spilling from bin/skip

  Fly tipping

• Who was involved (Use initials only)

• What was the immediate response.

  Spare

• Description of the incident in detail

• Did anyone witness the incident

  Yes

  No

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

  Yes

  No

• Attach statement(s) here

  Confirmed

• Take statement(s) and attach here

  Confirmed

• What was the cause of the utility issue.

  Select Combination of gas heating, air conditioning or open doors/windows working against each other. Electrical machinery/devices left on for excessive periods/overnight when not in use. Gas heating systems left on or not moved to tick-over mode when office unoccupied during the evening/weekend. Warehouse heating/temperature control systems left on with doors/shutters left open. Water outlets for cleaning, vehicle washing or welfare left running unnecessarily. Fluid/Fuel leak of a vehicle/plant/tank (3rd party owned) Fluid/Fuel leak of a vehicle/plant/tank (DBS Owned) Leak from customer owned goods Drainage system failure Gutting overflowing Office flooded - Unable to operate Office flooded - Able to operate but with distruptions Roof leaking Weather damage to doors, gates, roof walls and/or windows Yard flooded - Unable to operate Yard flooded - Able to operate but with disruptions. Arson/deliberate act. Carelessness by individual (E.g. discarded smoking materials). Electrical fault (fixed wiring) Issues during repairs/modifications to equipment/facility (3rd Party Contractors) Reactions from hazardous materials Stand alone office/warehouse devices creating fumes, overheating or smoking. Electrical fault (cables/equipment). Extreme wet/windy weather/storm Burst Pipes Taps/water outlets left running

  • Combination of gas heating, air conditioning or open doors/windows working against each other.
  • Electrical machinery/devices left on for excessive periods/overnight when not in use.
  • Gas heating systems left on or not moved to tick-over mode when office unoccupied during the evening/weekend.
  • Warehouse heating/temperature control systems left on with doors/shutters left open.
  • Water outlets for cleaning, vehicle washing or welfare left running unnecessarily.
  • Fluid/Fuel leak of a vehicle/plant/tank (3rd party owned)
  • Fluid/Fuel leak of a vehicle/plant/tank (DBS Owned)
  • Leak from customer owned goods
  • Drainage system failure
  • Gutting overflowing
  • Office flooded - Unable to operate
  • Office flooded - Able to operate but with distruptions
  • Roof leaking
  • Weather damage to doors, gates, roof walls and/or windows
  • Yard flooded - Unable to operate
  • Yard flooded - Able to operate but with disruptions.
  • Arson/deliberate act.
  • Carelessness by individual (E.g. discarded smoking materials).
  • Electrical fault (fixed wiring)
  • Issues during repairs/modifications to equipment/facility (3rd Party Contractors)
  • Reactions from hazardous materials
  • Stand alone office/warehouse devices creating fumes, overheating or smoking.
  • Electrical fault (cables/equipment).
  • Extreme wet/windy weather/storm
  • Burst Pipes
  • Taps/water outlets left running

• Who was involved (Use initials only)

• What was the immediate response (ADD DETAILED DROPDOWN)

  Spare

• Description of the incident in detail

• Did anyone witness the event.

  Yes

  No

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

  Yes

  No

• Attach statement(s) here.

  Confirmed

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

  Confirmed

• What was the cause of the fire.

  Spare

• Description of the incident in detail

• What was the immediate response.

  Spare

• Did anyone witness the event

  Yes

  No

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

  Yes

  No

• Attach the witness statement(s) here.

  Confirmed

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

  Confirmed

• What was the cause of the fire.

  Spare

• Who was involved (Use initials only).

• Description of the incident in detail

• What was the immediate response

  Spare

• Did anyone witness the event

  Yes

  No

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

  Yes

  No

  N/A

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

  Confirmed

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

  Confirmed

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

  Spare

Initial Containment

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

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

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

  Select Lessons Learnt communicated Re-training Other

  • Lessons Learnt communicated
  • Re-training
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

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

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Root cause analysis

• 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

  

• Which root cause analysis will you use?

  Select 5 Why Ishikawa Other

  • 5 Why
  • Ishikawa
  • Other
5 Why Analysis (click on the green + button to add analysis)

• What is the problem you are going to root cause analyse

• Why?

• Why?

• Why?

• Why?

• Why?

• Include evidence of your Ishikawa

• Which root cause analysis tool did you use? (provide evidence of methodology)

• What was determined as the root cause of this accident?

• Include your actions to prevent the action from reoccurring

Verification of corrective actions

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

  Yes

  No

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

  Yes

  No

Prevent Recurrence

• The problem has reoccurred since implementation of all actions.

  yes

  no

• Has the procedure/ risk assessment/ process been updated?

  Yes

  No

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

  Yes

  No

• Has the corrective action been witnessed?

  Yes

  No

Sign off

• Has the QSHE been contacted to inform them of the closure of the investigation?

  Yes

  No

• Provide evidence that the QSHE has been contacted

• Include an action to contact QSHE

• Team Leader sign off:

  Sign

• Completion Date

  Date

• This accident requires a level two investigation

• When was the accident?

  Date

• Where did the accident occour in the facility?

  Warehouse

  Office

  Yard

  Offsite

  Whole Facility

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

  Select Blade/ Knife Compactors Contractor owned equipment Customer Property - Damaged upon receipt Customer Property - Damaged within the facility Dangerous Goods Item Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, skates, hooks etc) MHE ( FLT, PPR, Wave, Turret etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck (Contractor owned) Road Van/Truck (DBS owned) Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Customer Property - Damaged upon receipt
  • Customer Property - Damaged within the facility
  • Dangerous Goods Item
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, skates, hooks etc)
  • MHE ( FLT, PPR, Wave, Turret etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck (Contractor owned)
  • Road Van/Truck (DBS owned)
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Who was involved (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

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

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

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

• What was the immediate response?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Ambulance required Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Ambulance required
  • Communication to effected parties

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

• Were any witness statements documented?

  Yes

  No

• Please attach the documents

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

• Does a risk assessment exist for this task?

  Yes

  No

• Has the risk assessment been reviewed?

  Yes

  No

• 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

  

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

  

• What was the potential cause of this accident?

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

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

  Select Lessons Learnt communicated Re-training Other

  • Lessons Learnt communicated
  • Re-training
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

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

• Provide evidence of the completed action

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

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

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

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

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Completion

• Name of person completing report

  Sign

• QSHE SOP 031 Non-conformance process

  

• What is the non-conformance level?

  Select Potential Cluster of Potential incidents Minor Major Significant Colleague illness (not work related accident)

  • Potential
  • Cluster of Potential incidents
  • Minor
  • Major
  • Significant
  • Colleague illness (not work related accident)

• Issue Type

  Select Service Performance Damage Delay DBS Warehouse DBS Control Tower GPS Tracking PPE Other

  • Service Performance
  • Damage
  • Delay
  • DBS Warehouse
  • DBS Control Tower
  • GPS Tracking
  • PPE
  • Other

• What is the damage type?

  Select - Cosmetic Damage - Indicator Triggered - Irregularity - Lost/Stolen - Rejected - Any other incident

  • - Cosmetic Damage
  • - Indicator Triggered
  • - Irregularity
  • - Lost/Stolen
  • - Rejected
  • - Any other incident

• Has a non-conformance been previously issued for the same issue?

  Yes

  No

• Please list applicable NC reference number(s)

• What customer/ supplier is involved? (include contact details)

• Customer reference number (e.g. HAWB/ MAWB)

• Please describe the non-conformance in detail

• To support the descriptions of the issue, add screen shots of e-mails, documents etc.

  Media

Initial response

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

• Include screen shots of communication and additional information where possible

  Media

• (e.g. product placed in quarantine, area cordoned off, additional communication to effected persons)

• Has the customer/ supplier been contacted after the initial response?

  Yes

  No

• Provide evidence that the customer/ supplier has been contacted

• Include an action to contact the customer/ supplier

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

  

• Which root cause analysis will you use?

  Select 5 Why Ishikawa Other

  • 5 Why
  • Ishikawa
  • Other
5 Why Analysis (click on the green + button to add analysis)

• What is the problem you are going to root cause analyse

• Why?

• Why?

• Why?

• Why?

• Why?

• Include evidence of your Ishikawa

• Which root cause analysis tool did you use? (provide evidence of methodology)

• What was determined as the root cause of this non-conformance?

• Include your actions to prevent the action from reoccurring

• Has the customer/ supplier been contacted to relay the corrective actions?

  Yes

  No

• Provide evidence that the customer/ supplier has been contacted

• Include an action to contact the customer/ supplier

Verification of corrective actions

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

  Yes

  No

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

  Yes

  No

7D: Prevent Recurrence

• The problem has reoccurred since implementation of all actions.

  yes

  no

• Has the procedure/ risk assessment/ process been updated?

  Yes

  No

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

  Yes

  No

• Has the corrective action been witnessed?

  Yes

  No

Sign off

• Has the customer/ supplier been contacted to inform them of the closure of the investigation?

  Yes

  No

• Provide evidence that the customer/ supplier has been contacted

• Include an action to contact the customer/ supplier

• Team Leader sign off:

  Sign

• Completion Date

  Date

• Yes

  No

  N/A