Injury Investigation

TYK Limited Accident and Incident Investigation

Investigation Details

• Safety Specialist leading the investigation?

  Elias Casillas

  Fernando Vazquez

  Rey Leyva

  Richard Rivera

• Date of this investigation.

  Date

• What kind of incident are you investigating?

  Accident

  Dangerous Occurence

  Near Miss

  Property Damage

Incident Details

• Name of injured person (if any)

• When did the incident occur?

  Date

• Was injury/incident reported within 24 hours?

  Yes

  No

  N/A

• If not, why?

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

  Select Head Face Eyes Neck Shoulders Arms Hands Fingers Chest Stomach Upper leg Lower leg Foot Toes

  • Head
  • Face
  • Eyes
  • Neck
  • Shoulders
  • Arms
  • Hands
  • Fingers
  • Chest
  • Stomach
  • Upper leg
  • Lower leg
  • Foot
  • Toes

• 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?

• 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

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 Machine Fault Electric Fault Not paying attention Inexperience Floor/Building condition Other

  • Machine Fault
  • Electric Fault
  • Not paying attention
  • Inexperience
  • Floor/Building condition
  • Other

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

  Select Failure to wear PPE Inadequate Training Improper behaviour Poor Housekeeping Other

  • Failure to wear PPE
  • Inadequate Training
  • Improper behaviour
  • Poor Housekeeping
  • Other

• 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?

• Did the injured person require time off work

  Yes

  No

  N/A

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/machinery have been damaged please list and describe the issues

Authorization

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

• Signed by Client Contact

  Sign

• Signed by Safety Specialist

  Sign