ECI-Automation - Incident Investigation

Information

Document No.
Short Incident Description
Site
Conducted on
Prepared by
Location
Investigation Team

Project/Incident Site

Job Number and Name of Project Where Incident Occurred
Address of Project
Manager on Site
Phone Number of Manager on Site
Current Amount of ECI-Automation Employees OnSite
Current schedule of project
Is there shift work?
Amount on Day Shift
Shift Schedule (begin and end)
Amount on Night Shift
Shift Schedule (begin and end)
Is there a safety coordinator assigned to the project
Safety Coordinator's name
Safety Coordinator's Telephone Number
Is there a forman assigned to the project?
Forman Name
Forman Telephone Number

Incident Investigation

What type of incident occurred?
- Spill
- Near Miss
- Property/Equipment Damage
- Injury
- Other
Name of Injured Employee
Classification/Job Title of Injured Employee
Date that Injured Employee was Hired
Home Address of Injured Employee
Home Telephone Number
Mobile Telephone Number
Date & Time of incident
Date & Time employee began work
Describe injury and parts of body affected
What object/substance directly injured the employee
Injured Employee: State in your own words description of pain/discomfort and location of injury.
Pain from scale 1-10
Was emergency services notified?
Provide reason why
Was on-site first aid treatment given?
Who administered first aid?
What first aid was performed? (ice, bandage, anti-bacterial cream, etc.)
Was employee transported to hospital or other medical provider?
Name of hospital or medical provider
Was employee transported by ambulance?
Where did the accident happen and who was involved? Provide a full description of the surroundings of the location and the individuals involved.
What was happening at the time of the accident and why was it taking place?
What were the events leading up to the accident? Describe the sequence in order and when they took place.
Has the employee performed the task before?
How many times and what training have they received pertaining to the task?
Photograph of certification (if available)
Have they received training in order to perform the task?
List training employee has received
Photograph of certification (if available)
List name of supervisor
Was there any equipment involved?
Describe equipment (provide detail, including serial numbers where available)
Were there any tools involved?
Describe tools used (provide detail, including serial numbers where available)
Has the injured employee ever injured this body part in the past?
Photographic Evidence
Sketch/diagram of incident scene
Add Property/Equipment
List Property/Equipment Damaged (list model number and serial number if available)
Estimated value of equipment or property.
Were any ECI-AUTOMATION personnel responsible for the operation of any equipment damaged?
Add Name
Employee Name
Has employee received training in operation of equipment?
List training
Photograph of certification (if available)
Name of employee's supervisor
Investigator: Describe the nature of the damaged property or equipment. What was damaged? To what extent? Is the equipment operable? Does it pose additional risk to operators in it's current state?
Photographic Evidence
Sketch/diagram of incident scene
What material spilled?
Approximately how much material spilled?
Did the spill enter a local waterway?
Has this been reported to the EPA?
Investigator: Briefly describe how the spill occurred
Photographic Evidence
Sketch/diagram of incident scene
Describe the near-miss incident. Investigator: enter names of people involved with near-miss in the witness area of form.
Describe the incident
Were safeguards or safety equipment provided?
What safeguards or safety equipment was provided?
Were safeguards or safety equipment used?
What safeguard or which safety equipment was not used?

Witness Statement

Add Witness
Witness Name
Classification/Job Title
Telephone Number
Date and Time of incident
Location where incident occurred.
Describe what you saw.
Who or what caused the incident?
In your opinion what body parts were injured?
Was there anything that could have been done to prevent injury?
What could have been done?
Did anything appear suspicious about the incident?
What was suspicious?
Witness signature

Root Cause Analysis (5 Why's)

Why?
Question
Answer
What is the root cause of this incident?

Findings

After review of all facts, what was the hazardous condition, unsafe work practice, or other causal factors (procedure, equipment, people and environment) that contributed to the incident?