fgf Accident/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
Project Manager/Site Foreman on Site
Phone Number of Project Manager/Site Foreman on Site
Describe scope of works and task being completed at time of Accident/Incident.

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/Mobile Telephone Number
Date & Time of incident
Describe injury and parts of body affected
What object/substance directly injured the employee
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 fgf 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 Accident/Incident.
Location where Accident/Incident occurred.
Describe what you saw.
Who or what caused the Accident/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 Accident/Incident?
What was suspicious?
Witness signature

Root Cause Analysis (5 Why's)

Why?
Question
Answer
What is the root cause of this Accident/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 Accident/Incident?

Preventative Action

What is recommended to prevent this type of Accident/Incident from occurring again?
Action taken to ensure recommendations are considered
Date by which all corrective measures will be implemented
Signature of supervisor responsible for corrections