Incident / Accident Investigation

• Document No.

• Incident type

• Client / Site

• Investigation Started On

  Date

• Prepared by

• Site Photo

  Media
• Location
  Address

• Personnel

• Background

• Conclusions Drawn

• Cost to the Organisation

Recommendations

• Recommendations

• Method of Investigation

• Initial Report Made by

• Method of reporting

  Select Accident report Phone Call Email Face to Face Fax Other

  • Accident report
  • Phone Call
  • Email
  • Face to Face
  • Fax
  • Other

• How Reported

• Date of Incident if Known

  Date

• Time of Incident if Known

  Date

• 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

  Date

To be carried out by the person responsible for Health & Safety

• Type of Incident

  Accident

  Near Miss

  Dangerous Occurance

• Potential for Harm

  Fatality

  Major Injuries

  Minor Injuries

  Property Damage

  None

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

• Copy of the incident report

  Media

• Is the incident reportable to the HSE under RIDDOR

  Yes

  No

  NA

• Date reported

  Date

• RIDDOR Incident Report Number

• Category

  Select 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

  • 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

• RIDDOR Report

  Media

• Managers Name

• Actions already taken by the Manager

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

1. Location of the Incident

• General Photo of Site

  Media
• Location
  Address

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?

  Yes

  No

  NA

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?

  Yes

  No

  N/A

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

  Yes

  No

  NA

• Were these Procedures Followed?

  Yes

  No

  N/A

7. Effect of the Incident

• How Affected

  Select 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

  • 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

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

  Select 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

  • 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

• Notes

• Description of object

• Dimensions; Height Width Depth Weight

• Approximate speed

• Photo

  Media

• 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

  Yes

  No

  N/A

• Type of Watercourse

• Are rescue aids available

  Yes

  No

  N/A

• 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)

  Yes

  No

  N/A

• Was the risk identified?

  Yes

  No

  N/A

• How is this risk controlled?

9. Organisation and Arrangement of the work

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

  Yes

  No

  NA

10. Maintenance

• Is the equipment/Area regularly checked for defect?

  Yes

  No

  N/A

• When was it last inspected?

  Date

• Were any defects noted?

  Yes

  No

  NA

• Is the maintenance and cleaning suitable and sufficient

  Yes

  No

  N/A

11. People Involved - Competencies

Person

• Name

• Can the competency of this person be demonstrated?

  Yes

  No

  N/A

• Qualifications?

  Yes

  No

  N/A

• Training?

  Yes

  No

  N/A

• Experience

  Yes

  No

  N/A

• Other?

  Yes

  No

  N/A

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

  Safe

  At Risk

  N/A

12. Workplace Layout

• Did the workplace layout influence the adverse effect?

  Safe

  At Risk

  N/A

13. Materials, Plant and Equipment

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

  Safe

  At Risk

  N/A

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

  Safe

  At Risk

  N/A

• Was the safety equipment suitable & sufficient?

  Yes

  No

  N/A

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

  Yes

  No

  NA

• Was it Issued?

  Yes

  No

  N/A

14. Other conditions

• Did any other conditions influence the advers event?

  Yes

  No

  NA

1. Immediate Cause

• Brief Description of the Immediate Cause

2. Route Cause Analysis Tree

• Analysis Tree

  Media

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?

  Safe

  At Risk

  N/A

• Who and Where?

• Have any similar incidents previously occurred within the organisation?

  Safe

  At Risk

  N/A

• Who and Where?

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

Control

• Control Description

1. Risk Assessment

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

  Yes

  No

  N/A

• Notes

• Date to be completed

  Date

• Responsible Person

2. Method of Work

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

  Yes

  No

  N/A

• Notes

• Date to be completed

  Date

• Responsible Person

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

  Sign

1. Legislation

Legislation

• Relevant Legislation

  Select 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

  • 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

• Specifics

2. Case Law

Relevant Cases

• Case Name

• Detail

• Press Cuttings

  Media

1. Physical Evidence

• Was any Equipment involved?

• Has it been seized / Taken out of use?

• Serial Number

• Description

• Photos

  Media

• Are there suitable and sufficient maintenance records?

  Yes

  No

  N/A

• Item

• Other Notes

2. Witnesses

• Name

• Has this person given a statement?

• Copy of Statement

  Media

• Any Special Notes

• Notes

3. Photographic Evidence

• Aerial View

  Media

• Other Photos

  Media

4. Documentation

Relevant Documents

• Document Name or Reference

• Document - Relevant Pages

  Media
Correspondance

• Method of Communication (add image if available)

  Email

  Letter

  Phonecall

• Text of email

• Copy of Letter

  Media

• Received

  Date

• Date/Time of call

  Date

• Call Between

• Notes made

• Image of notes if handwritten

  Media

5. Other Evidence

• Type

  Select Drawing Photo Audio/Video Weather Text Barcode

  • Drawing
  • Photo
  • Audio/Video
  • Weather
  • Text
  • Barcode

• Add drawing

  Drawing

• Add media

  Media

• Add media

  Media

• Add media

  Media

• undefined

• undefined

• undefined

• undefined