INCIDENT INVESTIGATION REPORT- version 1

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Type:

• Lost Time

• Area of Incident

• Incident Date:

  Date

• Location of Incident

• Investigator Name:

• Incident Reported By:

• Investigator Job Title:

• Date of Report:

  Date

• What happened and where? (Take photographs, and collect CCTV footage where possible)

• How did the incident occur? (Detail all factors leading to the incident)

• Why did the incident occur? (Was the task being rushed? Was there equipment failure? Human error?)

• Were any personal injuries sustained? (if yes, list below)

• Was first aid given? (if so, by whom)

Scene Investigation

• List the conditions of the scene (i. wet, dark. confined space, blind spot etc)

• Task and Competence (Details of the task and the competence of personnel involved)

• Were the personnel involved in the incident undertaking their normal duties?

  Yes

  No

  N/A

• Was the incident free of a third party?

  Yes

  No

  N/A

• Were the personnel involved competent in the task?

  Yes

  No

  N/A

• Are there documented training records for the personnel involved?

  Yes

  No

  N/A

• Was the task carried out in accordance with standard operating procedures?

  Yes

  No

  N/A

• Was PPE being worn?

  Yes

  No

  N/A

• List PPE being worn/ used

  Yes

  No

  N/A

• Was equipment involved in the incident?

  Yes

  No

  N/A

• List equipment being used

  Yes

  No

  N/A

• Was it the correct equipment for the task?

  Yes

  No

  N/A

• Were documented pre use checks carried out on the equipment being used? (Obtain report copy)

  Yes

  No

  N/A

• Has a competent person inspected the equipment involved? (Obtain report copy)

  Yes

  No

  N/A

• If equipment was involved, is it safe to continue operating?

  Yes

  No

  N/A

• If equipment was involved, have copies of the current servicing/ maintenance records been obtained?

  Yes

  No

  N/A

Witnesses

• Name of witness one Statement obtained?

  Yes

  No

  N/A

• Name of witness two Statement obtained?

  Yes

  No

  N/A

• Name of witness three Statement obtained?

  Yes

  No

  N/A

• List what immediate actions were taken post incident? (i.e., First aid given and by whom, equipment taken out of service)

Signatures

• Investigator

  Sign

• Person involved in incident

  Sign

• Date

  Date

CHECKLIST

• Accident book completed

  Yes

  No

  N/A

• Photographs taken

  Yes

  No

  N/A

• CCTV obtained

  Yes

  No

  N/A

• Statement from person(s) involved

  Yes

  No

  N/A

• Witness statements collected

  Yes

  No

  N/A

• Pre use check documentation

  Yes

  No

  N/A

Once completed hand this report to your line manager who will record the incident, it will then be forwarded onto Eddie Harris (Health & Safety)