Incident & Accident investigation

MARLEY ETERNIT LTD Accident and Incident Investigation

Investigation Details

• Who will be leading this investigation?

• Please enter the date of this investigation.

  Date

• What kind of incident are you investigating?

  Near miss

  Incident

  First Aid Incident

  Medical Aid Incident

  Fatality

• Please add the Envoy reference number this investigation relates too.

Incident Details

• Give details of incident

• When did the incident occur?

  Date

• Was anyone injured?

  Yes

  No

  N/A

• Name of injured person

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

  Select Head Eyes Body Leg Arm Hand(below wrist)

  • Head
  • Eyes
  • Body
  • Leg
  • Arm
  • Hand(below wrist)

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

• Have all persons involved in the incident received information, instruction and training for the tasks relating to the incident?

• Describe in detail what happened?

• Describe in detail any injury sustained, if no injury, describe any damaged equipment, plant or machinery etc

• Do you think any persons involved in the incident are negligent in any way, if yes, describe how.

• 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

  Yes

  No

  N/A

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

• Was any further treatment required

  Yes

  No

  N/A

• What was the outcome of this?

• Please provide dates and times

  Date

Witness Statement 1

• Please interview all witnesses and ask for signatures

• Name

• I confirm that the information I have provided in relation to this incident is accurate.

  Sign

• Select date

  Date

Witness Statement 2

• Please interview all witnesses and ask for signatures

• Name

• I confirm that the information I have provided in relation to this incident is accurate.

  Sign

• Select date

  Date

How did the incident/injury occur?

• Please list the main cause or causes of this incident or injury

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Please list any contributing factor or factors relating to this incident or injury

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Describe in detail your findings as to how the incident has occurred?

Corrective and Preventive Action

• What corrective actions have been taken immediately?

• Who carried out the corrective actions?

  Sign

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

• Provide a monthly timescale for any improvements that will be made?

Incident Reporting

• Did the injured person require time off work

  Yes

  No

  N/A

• Is this incident reportable under RIDDOR

  Yes

  No

  N/A

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

Results of Investigation

• 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.

• If any equipment, plant, machinery have been damaged please list and describe the issues

Authorisation

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

• Signed by injured person

  Sign

• Signed by Lead Investigator

  Sign