Information

  • Document No.

  • Incident type

  • Client / Site

  • Investigation Started On

  • Prepared by

  • Site Photo

  • Location
  • Personnel

Executive Summary

  • Background

  • Conclusions Drawn

  • Cost to the Organisation

  • Recommendations
  • Recommendations

  • Method of Investigation

Part 1 - To be Completed Immediately Upon Notification

  • Initial Report Made by

  • Method of reporting

  • How Reported

  • Date of Incident if Known

  • Time of Incident if Known

  • Number of Casualties

  • If there were more than 10 Casualties - How Many?

  • Other Notes

  • 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

  • Type of Incident

  • Potential for Harm

  • Incident Number and description of incident including any information onwhy the correct method was not used.

  • Copy of the incident report

  • Is the incident reportable to the HSE under RIDDOR

  • Date reported

  • RIDDOR Incident Report Number

  • Category

  • RIDDOR Report

  • Managers Name

  • Actions already taken by the Manager

  • Further people involved in the investigation including how involved and/or job title

Part 3 - Investigation Information Gathering

1. Location of the Incident

  • General Photo of Site

  • Location

2. About the Injured Person/s

    Was there an injury?
  • Name of person who was injured / suffered ill health or was otherwise harmed with the incident.

  • Address

  • Was the injured person alone?

3. How did the incident Happen - (Note any Equipment involved)

  • Description of Incident

4. What Activity was taking place

  • Activity/ies

5. Was there anything different from the norm or unusual about the working conditions? (Include weather conditions if known/relevant)

  • Conditions

6. Working Procedures

  • Are there adequate documented safe working procedures?

  • Would it be reasonable to assume that a safe Working Procedure or Method Statement should have been produced?

  • Were these Procedures Followed?

7. Effect of the Incident

  • How Affected

  • If there was an injury, how did it Occur and what caused it

  • Notes

  • Description of object

  • Dimensions; Height Width Depth Weight

  • Approximate speed

  • Photo

  • Name of Assailant if known

  • Notes

  • Type of object (e.g. knife / glass...)

  • Source of Electricity

  • Voltage

  • Make and Model of Machinery

  • Colour

  • Serial Number

  • Are all safeguards still in place

  • Type of Watercourse

  • Are rescue aids available

  • Cause of explosion (eg gas bottle..)

  • Extent of damage (100metres ...)

8. Risk Assessment

  • Is there a documented risk assessment for the task? (if yes, include a copy)

  • Was the risk identified?

  • How is this risk controlled?

9. Organisation and Arrangement of the work

  • Did the organisation and arrangement of the work influence the adverse effect?

10. Maintenance

  • Is the equipment/Area regularly checked for defect?

  • When was it last inspected?

  • Were any defects noted?

  • Is the maintenance and cleaning suitable and sufficient

11. People Involved - Competencies

    Person
  • Name

  • Can the competency of this person be demonstrated?

  • Qualifications?

  • Training?

  • Experience

  • Other?

  • Is there anything about this person that would increase the risk? e.g. were they alone?

12. Workplace Layout

  • Did the workplace layout influence the adverse effect?

13. Materials, Plant and Equipment

  • Did the nature or shape of the materials influence the adverse event?

  • Did difficulties in using the plant/equipment influence the adverse effect?

  • Was the safety equipment suitable & sufficient?

  • Was PPE required? If so what would be reasonably expected.

  • Was it Issued?

14. Other conditions

  • Did any other conditions influence the advers event?

Part 4 - Analysis

1. Immediate Cause

  • Brief Description of the Immediate Cause

2. Route Cause Analysis Tree

  • Analysis Tree

3. Underlying Causes

  • Underlying Cause List

4. Route Causes

    Identified Route Causes
  • Heading

  • Descritption

5. Similar Risks

  • Are any other areas within the organisation have similar risks?

  • Who and Where?

  • Have any similar incidents previously occurred within the organisation?

  • Who and Where?

Part 5 - Control Measures Required

  • These will be seen at the start of the document as actions required.

  • Control
  • Control Description

Part 6 - Risk Action Plan

1. Risk Assessment

  • Is the Risk Assessment Suitable and Sufficient as it stands?

  • Notes

  • Date to be completed

  • Responsible Person

2. Method of Work

  • Is the Method Statement / Safe Working Practice Suitable and Sufficient?

  • Notes

  • Date to be completed

  • Responsible Person

Part 7 - General

1. Costs

  • Estimated Cost | Item

  • Total Cost (£)

2. Personnel

  • Members of the Investigation team (Name and Position)

  • Distribution List (Name and Position)

  • Signed on behalf of the Investigation Team

addendum 1 - Relevant Legislation

1. Legislation

    Legislation
  • Relevant Legislation

  • Specifics

2. Case Law

    Relevant Cases
  • Case Name

  • Detail

  • Press Cuttings

Addendum 2 - Evidence Gathered

1. Physical Evidence

  • Was any Equipment involved?

  • Has it been seized / Taken out of use?

  • Serial Number

  • Description

  • Photos

  • Are there suitable and sufficient maintenance records?

  • Item

  • Other Notes

2. Witnesses

  • Name

  • Has this person given a statement?

  • Copy of Statement

  • Any Special Notes

  • Notes

3. Photographic Evidence

  • Aerial View

  • Other Photos

4. Documentation

    Relevant Documents
  • Document Name or Reference

  • Document - Relevant Pages

  • Correspondance
  • Method of Communication (add image if available)

  • Text of email

  • Copy of Letter

  • Received

  • Date/Time of call

  • Call Between

  • Notes made

  • Image of notes if handwritten

5. Other Evidence

  • Type

  • Add drawing

  • Add media

  • Add media

  • Add media

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  • undefined

  • undefined

  • undefined

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.