HE051 -Accident investigation - V1 04/08/23

Accident investigation

• This accident investigation report is used to determine the root cause of the accident to prevent future accidents. Health & Safety officer and Department heads (who are trained ) can use this accident investigation form during accident investigations. With the support of this investigation form, you are empowered to:

• 1 -Gather information regarding people involved in the accident.

• 2- Record accident details and describe consequences.

• 3 - Take optional photos for more context.

• 4 - Record witness statements if applicable.

• 5 - Recommend actions to avoid accident reoccurrence.

Investigation Details

• Who will be leading this investigation? (Provide name and designation)

• Please enter the date of this investigation.

  Date

• What kind of incident are you investigating?

  Accident

  Incident

  Near Miss

  Spillage

  others

• Please specify:

• Please add the accident report book number and page number (found top left hand corner of the book)

Incident Details

• Name of injured person (if any)

• Address of location where the accident/ incident occurred

• When did the incident occur?

  Date

• Whats the injured persons status on site? (if any)

  Contractor

  Visitor

  Heritage / Bestpac employee

  Agency employee

  Member of Public

About the Injury

• This is where investigating person will gather as much detail as possible about the injury.

  

• Has the injured person received first aid?

  No

  Yes

• What type of accident has occurred?

  Select Burn Chemical Cuts Electric Shock Eye Injury Fall Machinery Tools Manual Handling Occupational Health Pressure Release Scald Slip/Trip Vehicle

  • Burn
  • Chemical
  • Cuts
  • Electric Shock
  • Eye Injury
  • Fall
  • Machinery Tools
  • Manual Handling
  • Occupational Health
  • Pressure Release
  • Scald
  • Slip/Trip
  • Vehicle

• Which type of Injury is it?

  Select Amputation Bruise Burn Crushing Cut Dislocation Eye Injury Fatality Fracture Graze/Blister Impalement Internal Injury Laceration Scald Sprain Strain Other

  • Amputation
  • Bruise
  • Burn
  • Crushing
  • Cut
  • Dislocation
  • Eye Injury
  • Fatality
  • Fracture
  • Graze/Blister
  • Impalement
  • Internal Injury
  • Laceration
  • Scald
  • Sprain
  • Strain
  • Other

• Provide clear description of what Injury has occurred?

• Which side of the body is the injury on?

  Right

  Left

• Which part of the body was injured? (if any)

  Select Head Face Eyes Neck Shoulders Arms Hands Fingers Chest Upper leg Lower leg Foot Toes

  • Head
  • Face
  • Eyes
  • Neck
  • Shoulders
  • Arms
  • Hands
  • Fingers
  • Chest
  • Upper leg
  • Lower leg
  • Foot
  • Toes

• Give details of any tasks being carried out at the time of the incident/injury?

• Please add as many images as you can that relate to the incident.

  Media

• List all witnesses of the incident

Medical Treatment

• Was First Aid administered on-site

  No

  Yes

• Why not?

• Name of the First Aider?

• Please provide dates and times

  Date

• Describe what assistance was provided by the First Aider, list any medical equipment used (plasters, bandage, eyewash etc.)

  Select Plaster/s Bandage/s Eyewash Ice pack Compression pack Elevation kit Others

  • Plaster/s
  • Bandage/s
  • Eyewash
  • Ice pack
  • Compression pack
  • Elevation kit
  • Others

• Provide details of others assistance given to the injured person.

• Which action was taken Immediately following the treatment of the injured person

  Select A&E Continued Working GP Visit Urgent Care

  • A&E
  • Continued Working
  • GP Visit
  • Urgent Care

• If continued working, have they continued with duties which had been allocated prior to the injury?

  No

  Yes

• Obtain signature of First Aider

  Sign

Absence

• Has there been any absence because of injury sustained?

  YES

  NO

• If yes, How Long?

• Lost time from work must be reported to the H&S Officer, who will report to the Group as relevant.

• The above is an accurate account sustained.

• Signature of person reporting their injury / incident or near work instructions

  Sign

Identifying root cause

• What time did the person reporting the ACCIDENT/ INCIDENT start work?

  6-2

  2-10

  10-6

  Other

• Please state time?

  Date

• What activity were they involved in at the time of the ACCIDENT/ INCIDENT?

• Were they trained & authorised to be carrying out this activity?

  No

  Yes

• Is there a WORK INSTRUCTIONS in place? (if yes, attach copy via desk top or take images and add document title and reference number)

  No

  Yes

• Why not? (Answer can be obtained from department head/ HR manager)

• Have they had training in this activity? (Attach copy of training record)

  No

  Yes

• Have they been trained on the WORK INSTRUCTIONS and risk assessment? (if yes, attach copy via desk top or take images)?

  No

  Yes

• Why not?

• What Personal Protective Equipment was required for this activity?

  Select Body protection - overalls, aprons and coveralls (protection against hazardous substances) Body protection - clothing for hot, cold or bad weather Body protection - clothing to protect against machinery Body protection - high visibility (jackets, trousers and vests) Eye protection - Safety Goggles, Face shields Hand and arm protection - Gloves or gauntlets (leather, latex, nitrile, plastic coated, chain mail, etc) Hearing protection- Ear plugs/muffs Head protection - Industrial safety helmets (hard hats) Head protection - Industrial scalp protectors (bump caps) Respiratory Protective Equipment (RPE) -Mask Safety Harness Safety Shoes Wrist cuff armlets (e.g. used in glass cutting and handling)

  • Body protection - overalls, aprons and coveralls (protection against hazardous substances)
  • Body protection - clothing for hot, cold or bad weather
  • Body protection - clothing to protect against machinery
  • Body protection - high visibility (jackets, trousers and vests)
  • Eye protection - Safety Goggles, Face shields
  • Hand and arm protection - Gloves or gauntlets (leather, latex, nitrile, plastic coated, chain mail, etc)
  • Hearing protection- Ear plugs/muffs
  • Head protection - Industrial safety helmets (hard hats)
  • Head protection - Industrial scalp protectors (bump caps)
  • Respiratory Protective Equipment (RPE) -Mask
  • Safety Harness
  • Safety Shoes
  • Wrist cuff armlets (e.g. used in glass cutting and handling)

• Was PPE E.g. Shoes / Gloves / Glasses / Masks inspected at time of ACCIDENT/ INCIDENT?

  No

  Yes

• Why Not? (Provide a valid explanation to support this investigation)

• What was noted on inspection of PPE / or area?

• Was PPE acceptable and in good order?

  No

  Yes

• Has physical evidence of the PPE in use been retained? (If Yes describe details of retained evidence)

  Yes

  No

  None

• What tools / equipment / machinery was being used at the time of the report?

• Was the area clean, tidy, and free from obstruction? (Attach photographs)

  No

  Yes

• Has a copy of cleaning area cleaning schedule been attached to the investigation document?

  No

  Yes

• Why not?

• Was the area well lit and visibility clear?

  No

  Yes

• Plan drawing of scene or photos attached (Draw a sketch of location and attached images)

  Media

• Immediate Cause: (The features of an incident/accident which immediately contributed to harm or damage being caused. Example - if an employee is injured by items falling off shelving, the items falling and striking the employee is an immediate cause.)

• Contributing Factor: (Lack of proper information or training, unsafe systems of work, poorly maintained or unsuitable equipment, poor planning, unclear responsibilities, poor supervision.)

• Defences in place which failed: ( The work instruction in place for the particular task were out of date. Following updates and upgrades a risk assessment should have occurred)

• Defences in place which worked: ( Training on PPE and instructions on PPE at work were followed. (Employee had worn the correct PPE - Hard hat and safety shoes)

5 Whys

• 

• Why 1

• Why 2

• Why 3

• Why 4

• Why 5

Corrective and Preventive Action

• What corrective actions have been taken immediately?

• Who carried out the corrective actions?

• Describe what actions can be taken to prevent a recurrence of this incident (Improved training, PPE, improved housekeeping, improved maintenance etc)

• Provide a timescale for any improvements that will be made? (Slider - reference to number of days required to complete the improvements)

Authorisation

• Signature of Investigating manager:

  Sign

• Explain the results of your findings, take into account all factors and provide a balanced view, if there is a clear cause for the incident, be sure to list it.

• Please attach all supporting documents in relation to this investigation via upload media (copies of any documentation records or training)

  Media

• I agree that all information provided by this investigation is accurate.

• Signed by injured person

  Sign

• Signed by Lead Investigator

  Sign

Recommendations of the Dept Head and H&S dept

• Actions (What task is recommended)

• Allocated to? (name of person and dept.)

• Completion date: (By when these should be completed)

  Date

Incident Reporting

• Did the injured person require time off work

  YES

  NO

• How long?

• Is this incident reportable under RIDDOR

  Yes

  No

  None

• Report now or check if reportable at the Riddor site online
  http://www.hse.gov.uk/riddor