Information
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Document No.
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Incident type
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Client / Site
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Investigation Started On
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Prepared by
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Site Photo
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Location
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Personnel
Executive Summary
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Background
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Conclusions Drawn
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Cost to the Organisation
Recommendations
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Recommendations
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Method of Investigation
Part 1 - To be Completed Immediately Upon Notification
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Initial Report Made by
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Method of reporting
- Accident report
- Phone Call
- Face to Face
- Fax
- Other
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How Reported
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Date of Incident if Known
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Time of Incident if Known
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If there were more than 10 Casualties - How Many?
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Other Notes
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Date that the report was made to the Corporate & Public Safety Unit
Part 2 - Initial Assessment
To be carried out by the person responsible for Health & Safety
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Type of Incident
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Potential for Harm
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Incident Number and description of incident including any information onwhy the correct method was not used.
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Copy of the incident report
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Is the incident reportable to the HSE under RIDDOR
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Date reported
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RIDDOR Incident Report Number
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Category
- Fatality
- Fracture
- Laceration
- Incision
- Puncture
- Abrasion
- Contusion
- Sprain
- Strain
- Dislocation
- Burn
- Scald
- Chemical
- Loss of Sight
- Amputation
- Drown/ Asphyxia
- Medical
- Other
- No Injury
- Property Damage
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RIDDOR Report
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Managers Name
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Actions already taken by the Manager
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Further people involved in the investigation including how involved and/or job title
Part 3 - Investigation Information Gathering
1. Location of the Incident
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General Photo of Site
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Location
2. About the Injured Person/s
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Was there an injury?
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Name of person who was injured / suffered ill health or was otherwise harmed with the incident.
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Address
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Was the injured person alone?
3. How did the incident Happen - (Note any Equipment involved)
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Description of Incident
4. What Activity was taking place
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Activity/ies
5. Was there anything different from the norm or unusual about the working conditions? (Include weather conditions if known/relevant)
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Conditions
6. Working Procedures
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Are there adequate documented safe working procedures?
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Would it be reasonable to assume that a safe Working Procedure or Method Statement should have been produced?
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Were these Procedures Followed?
7. Effect of the Incident
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How Affected
- Fatality
- Fracture
- Laceration
- Incision
- Puncture
- Abrasion
- Contusion
- Sprain
- Strain
- Dislocation
- Burn
- Scald
- Chemical
- Loss of Sight
- Amputation
- Drown/ Asphyxia
- Medical
- Other
- No Injury
- Property Damage
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If there was an injury, how did it Occur and what caused it
- Assault
- Abuse
- Cut by Sharp Object
- Electrical
- Caught in Machinary
- Asphyxia/Drowning
- Explosion
- Contact with Fire or Hot Object
- Hit by Moving Object
- Hit something Stationary
- Hit by Vehicle
- Injured by plant or animal
- Lifting / Carrying
- Slip, Trip, Stumble or fall
- Fall From Height
- Contact with Hot Liquid
- Contact with chemical substance
- Medical Condition
- Near Miss
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Notes
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Description of object
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Dimensions; Height Width Depth Weight
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Approximate speed
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Photo
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Name of Assailant if known
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Notes
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Type of object (e.g. knife / glass...)
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Source of Electricity
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Voltage
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Make and Model of Machinery
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Colour
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Serial Number
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Are all safeguards still in place
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Type of Watercourse
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Are rescue aids available
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Cause of explosion (eg gas bottle..)
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Extent of damage (100metres ...)
8. Risk Assessment
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Is there a documented risk assessment for the task? (if yes, include a copy)
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Was the risk identified?
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How is this risk controlled?
9. Organisation and Arrangement of the work
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Did the organisation and arrangement of the work influence the adverse effect?
10. Maintenance
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Is the equipment/Area regularly checked for defect?
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When was it last inspected?
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Were any defects noted?
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Is the maintenance and cleaning suitable and sufficient
11. People Involved - Competencies
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Person
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Name
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Can the competency of this person be demonstrated?
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Qualifications?
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Training?
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Experience
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Other?
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Is there anything about this person that would increase the risk? e.g. were they alone?
12. Workplace Layout
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Did the workplace layout influence the adverse effect?
13. Materials, Plant and Equipment
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Did the nature or shape of the materials influence the adverse event?
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Did difficulties in using the plant/equipment influence the adverse effect?
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Was the safety equipment suitable & sufficient?
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Was PPE required? If so what would be reasonably expected.
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Was it Issued?
14. Other conditions
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Did any other conditions influence the advers event?
Part 4 - Analysis
1. Immediate Cause
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Brief Description of the Immediate Cause
2. Route Cause Analysis Tree
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Analysis Tree
3. Underlying Causes
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Underlying Cause List
4. Route Causes
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Identified Route Causes
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Heading
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Descritption
5. Similar Risks
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Are any other areas within the organisation have similar risks?
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Who and Where?
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Have any similar incidents previously occurred within the organisation?
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Who and Where?
Part 5 - Control Measures Required
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These will be seen at the start of the document as actions required.
Control
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Control Description
Part 6 - Risk Action Plan
1. Risk Assessment
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Is the Risk Assessment Suitable and Sufficient as it stands?
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Notes
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Date to be completed
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Responsible Person
2. Method of Work
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Is the Method Statement / Safe Working Practice Suitable and Sufficient?
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Notes
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Date to be completed
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Responsible Person
Part 7 - General
1. Costs
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Estimated Cost | Item
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Total Cost (£)
2. Personnel
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Members of the Investigation team (Name and Position)
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Distribution List (Name and Position)
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Signed on behalf of the Investigation Team
addendum 1 - Relevant Legislation
1. Legislation
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Legislation
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Relevant Legislation
- Health & Safety at Work Etc Act 1974
- Management of Health & Safety at Work Regulations
- Control of Asbestos Regualtions 2012
- Construction (Design and Management) Regulations 2015 (CDM 2015)
- Confined Spaces Regulations 1997
- Control of Substances Hazardous to Health Regulations 2002
- Safety Representatives and Safety Committees Regulations 1977 (as amended)
- Dangerous Substances and Explosive Atmospheres Regulations 2002.
- Work with display screen equipment: Health and Safety (Display Screen Equipment) Regulations 1992 as amended by the Health and Safety (Miscellaneous Amendments) Regulations 2002
- Health and Safety (First-Aid) Regulations 1981
- Control Of Legionella
- Lifting Operations and Lifting Equipment Regulations 1998
- Manual Handling Operations Regulations 1992 (as amended)
- Control of Noise at Work Regulations 2005
- Personal Protective Equipment at Work Regulations 1992 (as amended)
- Pressure Systems Safety Regulations 2000
- Radiation (Emergency Preparedness and Public Information) Regulations 2001
- Control of Vibration at Work Regulations 2005
- Workplace health, safety and welfare. Workplace (Health, Safety and Welfare) Regulations 1992
- Provision & Use of Workplace Equipment
- Other
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Specifics
2. Case Law
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Relevant Cases
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Case Name
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Detail
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Press Cuttings
Addendum 2 - Evidence Gathered
1. Physical Evidence
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Was any Equipment involved?
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Has it been seized / Taken out of use?
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Serial Number
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Description
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Photos
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Are there suitable and sufficient maintenance records?
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Item
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Other Notes
2. Witnesses
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Name
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Has this person given a statement?
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Copy of Statement
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Any Special Notes
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Notes
3. Photographic Evidence
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Aerial View
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Other Photos
4. Documentation
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Relevant Documents
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Document Name or Reference
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Document - Relevant Pages
Correspondance
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Method of Communication (add image if available)
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Text of email
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Copy of Letter
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Received
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Date/Time of call
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Call Between
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Notes made
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Image of notes if handwritten
5. Other Evidence
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Type
- Drawing
- Photo
- Audio/Video
- Weather
- Text
- Barcode
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Add drawing
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Add media
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Add media
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Add media