Incident and investigation form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Reference number (from the notification e-mail)

• Incident Summary

Incident Category:

• What is the loss category?

  Health & Safety

  Environment

• Incident definitions

  

• What is the accident category?

  Select Minor Major RIDDOR Colleague illness (not work related accident)

  • Minor
  • Major
  • RIDDOR
  • Colleague illness (not work related accident)

• Has this accident, or one similar to it, occurred on site within the last 30 days?

  Yes

  No

Define Problem

• When was the accident?

  Date

• Please describe the accident in detail

• Where did the accident occur?

  Select Warehouse Office Production Yard/ Car Park On the road Customer's site Other

  • Warehouse
  • Office
  • Production
  • Yard/ Car Park
  • On the road
  • Customer's site
  • Other

• Where did the accident occur?

• What equipment was involved in the accident (include photo)

  Select Blade/ Knife Compactors Contractor owned equipment Products (anything produced and sold by Culligan) Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, lifting equipment etc) MHE (FLT, PPR, etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Products (anything produced and sold by Culligan)
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, lifting equipment etc)
  • MHE (FLT, PPR, etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Who was the injured person (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

• What is their shift pattern?

  Day Shift

  Night Shift

  Crossover Shift

• Where on the body was their injury?

  Select Left side of body Right side of body

  • Left side of body
  • Right side of body

• Where specifically on the left side of the body?

  Select Head Face Ear/ hearing Eye Nose Mouth Neck Shoulder Arm Elbow Wrist Hand Finger Torso (inc back injury) Hips Buttocks Thigh Knee Calf Ankle Foot Toes

  • Head
  • Face
  • Ear/ hearing
  • Eye
  • Nose
  • Mouth
  • Neck
  • Shoulder
  • Arm
  • Elbow
  • Wrist
  • Hand
  • Finger
  • Torso (inc back injury)
  • Hips
  • Buttocks
  • Thigh
  • Knee
  • Calf
  • Ankle
  • Foot
  • Toes

• all head injuries will require a full investigation

• Circle the body part affected

  Drawing

• Where specifically on the right side of the body?

  Select Head Face Ear/ hearing Eye Nose Mouth Neck Shoulder Arm Elbow Wrist Hand Finger Torso (inc back injury) Hips Buttocks Thigh Knee Calf Ankle Foot Toes

  • Head
  • Face
  • Ear/ hearing
  • Eye
  • Nose
  • Mouth
  • Neck
  • Shoulder
  • Arm
  • Elbow
  • Wrist
  • Hand
  • Finger
  • Torso (inc back injury)
  • Hips
  • Buttocks
  • Thigh
  • Knee
  • Calf
  • Ankle
  • Foot
  • Toes

• all head injuries will require a full investigation

• Circle the body part affected

  Drawing

• What was the injury type?

  Select Cut Abrasion Pain Bruising Sprain Stab Burn / Scald Fracture Crush Non-Injury i.e. feeling faint or nausea

  • Cut
  • Abrasion
  • Pain
  • Bruising
  • Sprain
  • Stab
  • Burn / Scald
  • Fracture
  • Crush
  • Non-Injury i.e. feeling faint or nausea

• Is this occurrence related to a previously known medical condition or injury?

  Yes

  No

• Has this person received training in the task where the accident occurred?

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Was PPE required to be worn?

  Yes

  No

• Which PPE was required to be worn?

  Select Hard hat/ bump cap Hearing protection Eye protection Respiratory equipment Hand protection Hi-Vis clothing Safety footwear Fall arrest kit/ Harness

  • Hard hat/ bump cap
  • Hearing protection
  • Eye protection
  • Respiratory equipment
  • Hand protection
  • Hi-Vis clothing
  • Safety footwear
  • Fall arrest kit/ Harness

• Was the correct PPE being worn at the time of the accident?

  Yes

  No

• Does CCTV or video footage exist of the accident?

  Yes

  No

• Provide link to the footage or still screen shots

• What was the immediate response?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Communication to effected parties

• Who was the first aider? (please use initials only)

• Was treatment permitted?

  Yes

  No

• What first aid treatment was applied?

  Select Pressure/ elevation to stop bleeding Cleaning of wound Application of dressing Control of the accident area Calling emergency services Other

  • Pressure/ elevation to stop bleeding
  • Cleaning of wound
  • Application of dressing
  • Control of the accident area
  • Calling emergency services
  • Other

• Please specify first aid treatment applied

• What time were the emergency services called?

  Date

• What time did the emergency services arrive?

  Date

• Were any witness statements documented?

  Yes

  No

• Please attach the documents

• Was Violence or Aggression involved?

  Yes

  No

• The HR department must be involved

Completion

• Name of person completing report

  Sign

Define Problem

• When was the accident?

  Date

• Please describe the accident in detail

• Where did the accident occour in the facility?

  Select Warehouse Office Production Yard/ Car Park On the road Customer's site Other

  • Warehouse
  • Office
  • Production
  • Yard/ Car Park
  • On the road
  • Customer's site
  • Other

• What equipment was involved in the accident (include photo)

  Select Blade/ Knife Compactors Contractor owned equipment Products (anything produced and sold by Culligan) Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, lifting equipment etc) MHE (FLT, PPR, etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Products (anything produced and sold by Culligan)
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, lifting equipment etc)
  • MHE (FLT, PPR, etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Who was the injured person (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

• What is their shift pattern?

  Day Shift

  Night Shift

  Crossover Shift

• Where on the body was their injury?

  Select Left side of body Right side of body

  • Left side of body
  • Right side of body

• Where specifically on the left side of the body?

  Select Head Face Ear/ hearing Eye Nose Mouth Neck Shoulder Arm Elbow Wrist Hand Finger Torso (inc back injury) Hips Buttocks Thigh Knee Calf Ankle Foot Toes

  • Head
  • Face
  • Ear/ hearing
  • Eye
  • Nose
  • Mouth
  • Neck
  • Shoulder
  • Arm
  • Elbow
  • Wrist
  • Hand
  • Finger
  • Torso (inc back injury)
  • Hips
  • Buttocks
  • Thigh
  • Knee
  • Calf
  • Ankle
  • Foot
  • Toes

• all head injuries will require a full investigation

• Circle the body part affected

  Drawing

• Where specifically on the right side of the body?

  Select Head Face Ear/ hearing Eye Nose Mouth Neck Shoulder Arm Elbow Wrist Hand Finger Torso (inc back injury) Hips Buttocks Thigh Knee Calf Ankle Foot Toes

  • Head
  • Face
  • Ear/ hearing
  • Eye
  • Nose
  • Mouth
  • Neck
  • Shoulder
  • Arm
  • Elbow
  • Wrist
  • Hand
  • Finger
  • Torso (inc back injury)
  • Hips
  • Buttocks
  • Thigh
  • Knee
  • Calf
  • Ankle
  • Foot
  • Toes

• all head injuries will require a full investigation

• Circle the body part affected

  Drawing

• What was the injury type?

  Select Cut Abrasion Pain Bruising Sprain Stab Burn / Scald Fracture Crush Non-Injury i.e. feeling faint or nausea

  • Cut
  • Abrasion
  • Pain
  • Bruising
  • Sprain
  • Stab
  • Burn / Scald
  • Fracture
  • Crush
  • Non-Injury i.e. feeling faint or nausea

• Is this occurrence related to a previously known medical condition or injury?

  Yes

  No

• Has this person received training in the task where the accident occurred?

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Was PPE required to be worn?

  Yes

  No

• Which PPE was required to be worn?

  Select Hard hat/ bump cap Hearing protection Eye protection Respiratory equipment Hand protection Hi-Vis clothing Safety footwear Fall arrest kit/ Harness

  • Hard hat/ bump cap
  • Hearing protection
  • Eye protection
  • Respiratory equipment
  • Hand protection
  • Hi-Vis clothing
  • Safety footwear
  • Fall arrest kit/ Harness

• Was the correct PPE being worn at the time of the accident?

  Yes

  No

• What were the environmental conditions at the time of the accident?

  Select Sunny Raining Windy Overcast Snow/ Ice Extreme heat

  • Sunny
  • Raining
  • Windy
  • Overcast
  • Snow/ Ice
  • Extreme heat

• Does CCTV or video footage exist of the accident?

  Yes

  No

• Provide link to the footage or still screen shots

• What was the immediate response?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Communication to effected parties

• Who was the first aider? (please use initials only)

• Was treatment permitted?

  Yes

  No

• What first aid treatment was applied?

  Select Pressure/ elevation to stop bleeding Cleaning of wound Application of dressing Control of the accident area Calling emergency services Other

  • Pressure/ elevation to stop bleeding
  • Cleaning of wound
  • Application of dressing
  • Control of the accident area
  • Calling emergency services
  • Other

• Please specify first aid treatment applied

• What time were the emergency services called?

  Date

• What time did the emergency services arrive?

  Date

• Were any witness statements documented?

  Yes

  No

• Please attach the documents

• Was Violence or Aggression involved?

  Yes

  No

• The HR department must be involved

• RIDDOR Category

  Select Specified Injury Over Seven Day Incapacitation of a worker (ROI ONLY) Over Three Day Incapacitation of a worker Reportable Disease Dangerous Occurrence Injury to Non-Worker i.e. Visitor or Member of Public

  • Specified Injury
  • Over Seven Day Incapacitation of a worker
  • (ROI ONLY) Over Three Day Incapacitation of a worker
  • Reportable Disease
  • Dangerous Occurrence
  • Injury to Non-Worker i.e. Visitor or Member of Public

• RIDDOR Website England/ Scotland/ Wales: https://www.hse.gov.uk/riddor/report.htm

• RIDDOR Reference Number (attach a copy of the report to this pack)

• Who made the RIDDOR report? (print name)

• This incident does not require an investigation

• When was the incident?

  Date

• Describe the incident

• Where did the incident occur in the facility?

  Select Warehouse Office Production Yard/ Car Park On the road Customer's site Other

  • Warehouse
  • Office
  • Production
  • Yard/ Car Park
  • On the road
  • Customer's site
  • Other

• Who was involved (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

• What treatment was given?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Communication to effected parties

• Who was the first aider? (please use initials only)

• Has their manager been informed?

  Yes

  No

Sign off

• Name of person reporting incident

  Sign

• Incident definitions

• What is the environmental incident category?

  Select Minor Major RIDDOR Colleague illness (not work related accident)

  • Minor
  • Major
  • RIDDOR
  • Colleague illness (not work related accident)

Investigation Team

• Team leader

Team Members

• Name of Team member

Define Problem

• When was the incident.

  Date

• Where did the incident occur

  Select Warehouse Office Production Yard/ Car Park On the road Customer's site Other

  • Warehouse
  • Office
  • Production
  • Yard/ Car Park
  • On the road
  • Customer's site
  • Other

• What equipment/infrastructure/products/services/scenario involved.

  Chemical Spill

  Waste Management

  Utilities

  Fire

  Flood and Weather

• What was the cause of the chemical spill

  Select Loss of vehicle fuel containment Damaged chemical container Incorrect use of chemical During decanting process

  • Loss of vehicle fuel containment
  • Damaged chemical container
  • Incorrect use of chemical
  • During decanting process

• Description of the incident in detail

• What was your immediate response

  Select Access to site checked/made secure Air Con/heating switched off/windows closed. Alarm Raised (External) Alarm Raised (Internal System) Absorbent socks used to prevent spread Area cleared of excess water Area cleared of litter/dirt Bin/Skip covered/sealed Building Evacuated Customer stock removed from the area. Drains blocked with drain covers Doors closed in warehouse/temperature controlled areas. Equipment and machinery removed from the area. Equipment serviced/calibrated. Fire fighting/suppression equipment ordered/distributed. Fire tackled Leak plugged/sealed Leaking drum/vessel placed on bunded pallet Main site shut off taps closed. Nothing Spill kit and/or consumables ordered/distributed. Storage/spill bund drained of water. Storage/spill bund protected against weather Unused electrical devices turned off. Waste removed and placed in correct bins/skips Waste stored elsewhere (Temporary) Water outlets turned off Weeping/dripping valves/pipes repaired. Other

  • Access to site checked/made secure
  • Air Con/heating switched off/windows closed.
  • Alarm Raised (External)
  • Alarm Raised (Internal System)
  • Absorbent socks used to prevent spread
  • Area cleared of excess water
  • Area cleared of litter/dirt
  • Bin/Skip covered/sealed
  • Building Evacuated
  • Customer stock removed from the area.
  • Drains blocked with drain covers
  • Doors closed in warehouse/temperature controlled areas.
  • Equipment and machinery removed from the area.
  • Equipment serviced/calibrated.
  • Fire fighting/suppression equipment ordered/distributed.
  • Fire tackled
  • Leak plugged/sealed
  • Leaking drum/vessel placed on bunded pallet
  • Main site shut off taps closed.
  • Nothing
  • Spill kit and/or consumables ordered/distributed.
  • Storage/spill bund drained of water.
  • Storage/spill bund protected against weather
  • Unused electrical devices turned off.
  • Waste removed and placed in correct bins/skips
  • Waste stored elsewhere (Temporary)
  • Water outlets turned off
  • Weeping/dripping valves/pipes repaired.
  • Other

• Who was involved (Use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

• Has this person received training in the task where the accident occurred?

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

• Provide link to the footage or still screen shots

• Did anyone witness the event?

  Yes

  No

• Was a written witness statement(s) taken from the individuals?

  Yes

  No

• Attach witness statement to the report here.

• What was the cause of the waste issue

  Waste placed in wrong bin/skip

  Waste spilling from bin/skip

  Fly tipping

• Who was involved (Use initials only)

• What was the immediate response.

  Spare

• Description of the incident in detail

• Did anyone witness the incident

  Yes

  No

• Was a written statement(s) taken from the individuals?

  Yes

  No

• Attach statement(s) here

  Confirmed

• Take statement(s) and attach here

  Confirmed

• What was the cause of the utility issue.

  Select Combination of gas heating, air conditioning or open doors/windows working against each other. Electrical machinery/devices left on for excessive periods/overnight when not in use. Gas heating systems left on or not moved to tick-over mode when office unoccupied during the evening/weekend. Warehouse heating/temperature control systems left on with doors/shutters left open. Water outlets for cleaning, vehicle washing or welfare left running unnecessarily. Fluid/Fuel leak of a vehicle/plant/tank (3rd party owned) Fluid/Fuel leak of a vehicle/plant/tank (DBS Owned) Leak from customer owned goods Drainage system failure Gutting overflowing Office flooded - Unable to operate Office flooded - Able to operate but with distruptions Roof leaking Weather damage to doors, gates, roof walls and/or windows Yard flooded - Unable to operate Yard flooded - Able to operate but with disruptions. Arson/deliberate act. Carelessness by individual (E.g. discarded smoking materials). Electrical fault (fixed wiring) Issues during repairs/modifications to equipment/facility (3rd Party Contractors) Reactions from hazardous materials Stand alone office/warehouse devices creating fumes, overheating or smoking. Electrical fault (cables/equipment). Extreme wet/windy weather/storm Burst Pipes Taps/water outlets left running

  • Combination of gas heating, air conditioning or open doors/windows working against each other.
  • Electrical machinery/devices left on for excessive periods/overnight when not in use.
  • Gas heating systems left on or not moved to tick-over mode when office unoccupied during the evening/weekend.
  • Warehouse heating/temperature control systems left on with doors/shutters left open.
  • Water outlets for cleaning, vehicle washing or welfare left running unnecessarily.
  • Fluid/Fuel leak of a vehicle/plant/tank (3rd party owned)
  • Fluid/Fuel leak of a vehicle/plant/tank (DBS Owned)
  • Leak from customer owned goods
  • Drainage system failure
  • Gutting overflowing
  • Office flooded - Unable to operate
  • Office flooded - Able to operate but with distruptions
  • Roof leaking
  • Weather damage to doors, gates, roof walls and/or windows
  • Yard flooded - Unable to operate
  • Yard flooded - Able to operate but with disruptions.
  • Arson/deliberate act.
  • Carelessness by individual (E.g. discarded smoking materials).
  • Electrical fault (fixed wiring)
  • Issues during repairs/modifications to equipment/facility (3rd Party Contractors)
  • Reactions from hazardous materials
  • Stand alone office/warehouse devices creating fumes, overheating or smoking.
  • Electrical fault (cables/equipment).
  • Extreme wet/windy weather/storm
  • Burst Pipes
  • Taps/water outlets left running

• Who was involved (Use initials only)

• What was the immediate response (ADD DETAILED DROPDOWN)

  Spare

• Description of the incident in detail

• Did anyone witness the event.

  Yes

  No

• Was a written witness statement(s) taken from the individual

  Yes

  No

• Attach statement(s) here.

  Confirmed

• Take statement(s) and attach to the report here.

  Confirmed

• What was the cause of the fire.

  Spare

• Description of the incident in detail

• What was the immediate response.

  Spare

• Did anyone witness the event

  Yes

  No

• Was a written witness statement(s) taken from the individuals?

  Yes

  No

• Attach the witness statement(s) here.

  Confirmed

• Take statement(s) and attach to the report here.

  Confirmed

• What was the cause of the fire.

  Spare

• Who was involved (Use initials only).

• Description of the incident in detail

• What was the immediate response

  Spare

• Did anyone witness the event

  Yes

  No

• Was a written witness statement(s) taken from the individual(s)?

  Yes

  No

  N/A

• Take statements from the individual(s) and attach to the report here.

  Confirmed

• Attach the statement(s) to the incident report here.

  Confirmed

• What was the result of the flood or weather event?

  Spare

• The line manager is responsible for completing the online form https://www.gov.uk/report-an-environmental-incident (UK) / https://www.epa.ie/ (IRE). Support can be obtained from the EHS team healthandsafety.ukie@culligan.com and must inform their senior manager of the accident as soon as possible.

• Has this incident, or one similar to it, occurred on site within the last 30 days

  Yes

  No

• This incident requires a level one investigation

Investigation Team

• Team leader

Team Members

• Name of Team member

Define Problem

• When was the incident.

  Date

• Where did the incident occur

  Select Warehouse Office Production Yard/ Car Park On the road Customer's site Other

  • Warehouse
  • Office
  • Production
  • Yard/ Car Park
  • On the road
  • Customer's site
  • Other

• What equipment/infrastructure/products/services/scenario involved.

  Chemical Spill

  Waste Management

  Utilities

  Fire

  Flood and Weather

• What was the cause of the chemical spill

  Select Loss of vehicle fuel containment Damaged chemical container Incorrect use of chemical During decanting process

  • Loss of vehicle fuel containment
  • Damaged chemical container
  • Incorrect use of chemical
  • During decanting process

• Description of the incident in detail

• What was your immediate response

  Select Access to site checked/made secure Air Con/heating switched off/windows closed. Alarm Raised (External) Alarm Raised (Internal System) Absorbent socks used to prevent spread Area cleared of excess water Area cleared of litter/dirt Bin/Skip covered/sealed Building Evacuated Customer stock removed from the area. Drains blocked with drain covers Doors closed in warehouse/temperature controlled areas. Equipment and machinery removed from the area. Equipment serviced/calibrated. Fire fighting/suppression equipment ordered/distributed. Fire tackled Leak plugged/sealed Leaking drum/vessel placed on bunded pallet Main site shut off taps closed. Nothing Spill kit and/or consumables ordered/distributed. Storage/spill bund drained of water. Storage/spill bund protected against weather Unused electrical devices turned off. Waste removed and placed in correct bins/skips Waste stored elsewhere (Temporary) Water outlets turned off Weeping/dripping valves/pipes repaired. Other

  • Access to site checked/made secure
  • Air Con/heating switched off/windows closed.
  • Alarm Raised (External)
  • Alarm Raised (Internal System)
  • Absorbent socks used to prevent spread
  • Area cleared of excess water
  • Area cleared of litter/dirt
  • Bin/Skip covered/sealed
  • Building Evacuated
  • Customer stock removed from the area.
  • Drains blocked with drain covers
  • Doors closed in warehouse/temperature controlled areas.
  • Equipment and machinery removed from the area.
  • Equipment serviced/calibrated.
  • Fire fighting/suppression equipment ordered/distributed.
  • Fire tackled
  • Leak plugged/sealed
  • Leaking drum/vessel placed on bunded pallet
  • Main site shut off taps closed.
  • Nothing
  • Spill kit and/or consumables ordered/distributed.
  • Storage/spill bund drained of water.
  • Storage/spill bund protected against weather
  • Unused electrical devices turned off.
  • Waste removed and placed in correct bins/skips
  • Waste stored elsewhere (Temporary)
  • Water outlets turned off
  • Weeping/dripping valves/pipes repaired.
  • Other

• Who was involved (Use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

• Has this person received training in the task where the accident occurred?

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

• Provide link to the footage or still screen shots

• Did anyone witness the event?

  Yes

  No

• Was a written witness statement(s) taken from the individuals?

  Yes

  No

• Attach witness statement to the report here.

• What was the cause of the waste issue

  Waste placed in wrong bin/skip

  Waste spilling from bin/skip

  Fly tipping

• Who was involved (Use initials only)

• What was the immediate response.

  Spare

• Description of the incident in detail

• Did anyone witness the incident

  Yes

  No

• Was a written statement(s) taken from the individuals?

  Yes

  No

• Attach statement(s) here

  Confirmed

• Take statement(s) and attach here

  Confirmed

• What was the cause of the utility issue.

  Select Combination of gas heating, air conditioning or open doors/windows working against each other. Electrical machinery/devices left on for excessive periods/overnight when not in use. Gas heating systems left on or not moved to tick-over mode when office unoccupied during the evening/weekend. Warehouse heating/temperature control systems left on with doors/shutters left open. Water outlets for cleaning, vehicle washing or welfare left running unnecessarily. Fluid/Fuel leak of a vehicle/plant/tank (3rd party owned) Fluid/Fuel leak of a vehicle/plant/tank (DBS Owned) Leak from customer owned goods Drainage system failure Gutting overflowing Office flooded - Unable to operate Office flooded - Able to operate but with distruptions Roof leaking Weather damage to doors, gates, roof walls and/or windows Yard flooded - Unable to operate Yard flooded - Able to operate but with disruptions. Arson/deliberate act. Carelessness by individual (E.g. discarded smoking materials). Electrical fault (fixed wiring) Issues during repairs/modifications to equipment/facility (3rd Party Contractors) Reactions from hazardous materials Stand alone office/warehouse devices creating fumes, overheating or smoking. Electrical fault (cables/equipment). Extreme wet/windy weather/storm Burst Pipes Taps/water outlets left running

  • Combination of gas heating, air conditioning or open doors/windows working against each other.
  • Electrical machinery/devices left on for excessive periods/overnight when not in use.
  • Gas heating systems left on or not moved to tick-over mode when office unoccupied during the evening/weekend.
  • Warehouse heating/temperature control systems left on with doors/shutters left open.
  • Water outlets for cleaning, vehicle washing or welfare left running unnecessarily.
  • Fluid/Fuel leak of a vehicle/plant/tank (3rd party owned)
  • Fluid/Fuel leak of a vehicle/plant/tank (DBS Owned)
  • Leak from customer owned goods
  • Drainage system failure
  • Gutting overflowing
  • Office flooded - Unable to operate
  • Office flooded - Able to operate but with distruptions
  • Roof leaking
  • Weather damage to doors, gates, roof walls and/or windows
  • Yard flooded - Unable to operate
  • Yard flooded - Able to operate but with disruptions.
  • Arson/deliberate act.
  • Carelessness by individual (E.g. discarded smoking materials).
  • Electrical fault (fixed wiring)
  • Issues during repairs/modifications to equipment/facility (3rd Party Contractors)
  • Reactions from hazardous materials
  • Stand alone office/warehouse devices creating fumes, overheating or smoking.
  • Electrical fault (cables/equipment).
  • Extreme wet/windy weather/storm
  • Burst Pipes
  • Taps/water outlets left running

• Who was involved (Use initials only)

• What was the immediate response (ADD DETAILED DROPDOWN)

  Spare

• Description of the incident in detail

• Did anyone witness the event.

  Yes

  No

• Was a written witness statement(s) taken from the individual

  Yes

  No

• Attach statement(s) here.

  Confirmed

• Take statement(s) and attach to the report here.

  Confirmed

• What was the cause of the fire.

  Spare

• Description of the incident in detail

• What was the immediate response.

  Spare

• Did anyone witness the event

  Yes

  No

• Was a written witness statement(s) taken from the individuals?

  Yes

  No

• Attach the witness statement(s) here.

  Confirmed

• Take statement(s) and attach to the report here.

  Confirmed

• What was the cause of the fire.

  Spare

• Who was involved (Use initials only).

• Description of the incident in detail

• What was the immediate response

  Spare

• Did anyone witness the event

  Yes

  No

• Was a written witness statement(s) taken from the individual(s)?

  Yes

  No

  N/A

• Take statements from the individual(s) and attach to the report here.

  Confirmed

• Attach the statement(s) to the incident report here.

  Confirmed

• What was the result of the flood or weather event?

  Spare

• This accident requires a level two investigation

• When was the accident?

  Date

• Where did the accident occour in the facility?

  Select Warehouse Office Production Yard/ Car Park On the road Customer's site Other

  • Warehouse
  • Office
  • Production
  • Yard/ Car Park
  • On the road
  • Customer's site
  • Other

• What equipment was involved in the accident (include photo)

  Select Blade/ Knife Compactors Contractor owned equipment Products (anything produced and sold by Culligan) Display Screen Equipment Dock Leveller External Building damage Fire Equipment (extinguishers, alarms, lights, sounders) Hand tools (not including blades) Internal Buidling damage Manual Handling aids (trolleys, lifting equipment etc) MHE (FLT, PPR, etc) Office Seating Other Packaging material Pallets Racking Road Van/ Truck Roller Shutter door Waste

  • Blade/ Knife
  • Compactors
  • Contractor owned equipment
  • Products (anything produced and sold by Culligan)
  • Display Screen Equipment
  • Dock Leveller
  • External Building damage
  • Fire Equipment (extinguishers, alarms, lights, sounders)
  • Hand tools (not including blades)
  • Internal Buidling damage
  • Manual Handling aids (trolleys, lifting equipment etc)
  • MHE (FLT, PPR, etc)
  • Office Seating
  • Other
  • Packaging material
  • Pallets
  • Racking
  • Road Van/ Truck
  • Roller Shutter door
  • Waste

• Please describe equipment involved

• Who was involved (please use initials only)

• What is their employment status?

  Full time employee

  Part time employee

  Contractor

  Visitor

  Agency

• Has this person received training in the task where the accident occurred?

  Yes

  No

• Provide evidence of training such as certificate or attendance record

• What level of experience does this person have?

  Novice

  Competent

  Expert

  Trainer

• Please describe the accident in detail

• Does CCTV or video footage exist of the accident?

  Yes

  No

• Provide link in the notes to the location of the footage or still screen shots

• What was the immediate response?

  Select First Aid Quarantined the area/ equipment Walk-in center/ taken to A&E Communication to effected parties

  • First Aid
  • Quarantined the area/ equipment
  • Walk-in center/ taken to A&E
  • Communication to effected parties

• Who was the first aider? (please use initials only)

• Were any witness statements documented?

  Yes

  No

• Please attach the documents

• Obtain witness statements from the injured person, first aiders and any witnesses.

• Does a risk assessment exist for this task?

  Yes

  No

• Has the risk assessment been reviewed?

  Yes

  No

• The risk assessment must be reviewed before closing this investigation

• What is the risk assessment reference?

• A risk assessment must be devised and communicated. Please raise an action to complete an assessment as required in QSHE SOP 006

  

• For a level 2 investigation we use a simple Ishikawa principle to determine a potential root cause

  

• What was the potential cause of this accident?

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

• What corrective actions have been implemented to improve the human factor cause of this accident?

  Select Lessons Learnt communicated Re-trianing Other

  • Lessons Learnt communicated
  • Re-trianing
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• The investigation can not be closed until the action is completed

• Provide evidence of the completed action

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the materials used in this accident? (include details in the notes)

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the measurement aspects of this accident? (include details in the notes)

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the equipment used in this accident? (include details in the notes)

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe the action required to improve the equipment used in the accident

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the process related to this accident? (include details in the notes)

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the environment associated with this accident? (include details in the notes)

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Completion

• Name of person completing report

  Sign

Interim Containment

• Describe what has been put in place to stop the issue from escalating?

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

• What corrective actions have been implemented to improve the human factor cause of this accident?

  Select Lessons Learnt communicated Re-trianing Other

  • Lessons Learnt communicated
  • Re-trianing
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the materials used in this accident?

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the measurement aspects of this accident?

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the equipment used in this accident?

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe the action required to improve the equipment used in the accident

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the process related to this accident?

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the environment associated with this accident?

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Verify and Determine the root cause

• You can use the simple Ishikawa principle to determine a potential root cause as a brain storming tool with the colleagues or the 5 Why process

  

• Which root cause analysis will you use?

  Select 5 Why Ishikawa Other

  • 5 Why
  • Ishikawa
  • Other
5 Why Analysis (click the green + button to complete)

• What is the problem you are going to root cause analyse

• Why?

• Why?

• Why?

• Why?

• Why?

• As determined by the 5Why above, what are the Immediate/Direct Causes (circumstances that immediately precede the accident)

  Select Slip Trip Stab / Puncture Cut / Laceration Lifting / Carrying Pushing / Pulling Fall (same level) Fall from height Unauthorised use of equipment Not wearing required PPE Not following training Struck by moving vehicle Equipment Fault or Failure Personal attack Contact with moving machinery Struck by falling / flying objects Contact with electricty Struck against fixed / stationary object Removal of safety guards Exposure / contact with harmful substance(s) Burns / Scalds from exposure to Fire or Heat Trap or Pinch Horseplay Non- Injury i.e. fainting, nose bleed, black out, rash, bee sting, etc.

  • Slip
  • Trip
  • Stab / Puncture
  • Cut / Laceration
  • Lifting / Carrying
  • Pushing / Pulling
  • Fall (same level)
  • Fall from height
  • Unauthorised use of equipment
  • Not wearing required PPE
  • Not following training
  • Struck by moving vehicle
  • Equipment Fault or Failure
  • Personal attack
  • Contact with moving machinery
  • Struck by falling / flying objects
  • Contact with electricty
  • Struck against fixed / stationary object
  • Removal of safety guards
  • Exposure / contact with harmful substance(s)
  • Burns / Scalds from exposure to Fire or Heat
  • Trap or Pinch
  • Horseplay
  • Non- Injury i.e. fainting, nose bleed, black out, rash, bee sting, etc.

• As determined by the 5Why above, what is the Basic/Root Cause for the accident?

  Select Personal/ Human Factors Job/ System Factors

  • Personal/ Human Factors
  • Job/ System Factors

• What was the Person/ Human Factor Root cause?

  Select Lapse (When a person forgets to do something) Mistake (When a person does something they are meant to do but should have done something else) Violation (when a person decided to act without complying to a known rule/process)

  • Lapse (When a person forgets to do something)
  • Mistake (When a person does something they are meant to do but should have done something else)
  • Violation (when a person decided to act without complying to a known rule/process)

• Please detail the human factor root cause and create an action to rectify

• What is the job/ system factor of the root cause

  Select Process (incorrect documented process) Training (incorrect/ lack of training provided) Organisational (high workloads/ inadequate resources) Equipment (maintenance, availability, suitable for the task)

  • Process (incorrect documented process)
  • Training (incorrect/ lack of training provided)
  • Organisational (high workloads/ inadequate resources)
  • Equipment (maintenance, availability, suitable for the task)

• Please detail the system factor root cause and create an action to rectify

Prevent Recurrence

• Witihn 30 days of the accident, as the problem has reoccurred since implementation of all actions.

  yes

  no

• The root cause analysis should be reviewed and additional prevenatative actions implemented

• Does a risk assessment exist for this task?

  Yes

  No

• Has the risk assessment been reviewed?

  Yes

  No

• The risk assessment must be reviewed before closing this investigation

• What is the risk assessment reference?

• A risk assessment must be devised and communicated. Please raise an action to complete an assessment as required in QSHE SOP 006

  

• Has the procedure/ process been updated?

  Yes

  No

• Have the results and improvements been communicated to all affected persons?

  Yes

  No

• Has the corrective action been witnessed?

  Yes

  No

• If the answer is yes to all of the above in this section, then the investigation is ready to be closed

End of Investigation - Sign off

• What time was lost due to the accident (days)?

• A RIDDOR report must be completed https://www.hse.gov.uk/riddor/report.htm

• Team Leader sign off:

  Sign

• First Aider sign off:

  Sign