MEL Accident Investigation Report

• Document No.

• Date and Time of Incident

  Date

• Accident Incident Investigation Form Prepared by (full name, employee ID, position)

• Date and Time Accident Incident Investigation Form was initiated

  Date

• Area / Location of Accident

  Select press finishing warehouse shipping sheeting maintenance plate room exterior grounds UC Warehouse office area

  • press
  • finishing
  • warehouse
  • shipping
  • sheeting
  • maintenance
  • plate room
  • exterior grounds
  • UC Warehouse
  • office area

PERSONAL INFORMATION (injured employee)

• Employees full name

• Enter date and time of injury or accident

  Date

• Provide photos if available

  Media

Manager / Safety Team Investigation

• Employment Category

  Select Production Maintenance Fork lift driver Office Contractor Visitor

  • Production
  • Maintenance
  • Fork lift driver
  • Office
  • Contractor
  • Visitor

• Length of employment

  less than 1 month

  1 - 5 months

  6 months - 5 years

  more than 5 years

• Type of operation

  Cleaning

  Unjamming

  Normal Duties

  Driving

  Walking

• Was this operation a regular part of employees job?

  Yes

  No

  N/A

• Type of injury

  Select No injury First Aid Medical Treatment Lost Time Restricted Duty Fatality

  • No injury
  • First Aid
  • Medical Treatment
  • Lost Time
  • Restricted Duty
  • Fatality

ACCIDENT / INCIDENT SUMMARY

• We're there any witnesses to the incident? What are the witnesses names?

Accident Sequence - describe in reverse order the occurrence of events preceding the injury

• Incident Event / Accident Event

• Describe the preceding events that led up to the injury or accident

Preceding Events

• Was PPE required for this task?

  Yes

  No

  N/A

• What PPE was required and in use at time of incident

PPE REQUIRED

• Provided?

  Yes

  No

  N/A

• Trained on proper use?

  Yes

  No

  N/A

• Proper use of PPE?

  Yes

  No

  N/A

• PPE use enforced by manager and supervisor?

  Yes

  No

  N/A

• Was equipment adequately guarded? If no describe deficiency

  Yes

  No

  N/A

• Has employee received training prior to job assignment?

  Yes

  No

  N/A

• Was training adequate?

  Yes

  No

  N/A

• Where were you at the time of the incident?

QUESTIONNAIRE

• What time did the incident occur?

• What were you doing at the time of the incident

• What injury resulted from the incident?

• Was there any ergonomic (strain/sprain) from the incident?

  Yes

  No

  N/A

• We're any Pre-existing conditions with the injury area?

  Yes

  No

  N/A

• Did you have to

  Select Push Pull Bend Twist Lift

  • Push
  • Pull
  • Bend
  • Twist
  • Lift

• If moving a object what was the estimated weight?

• Did you ask for help with lifting?

  Yes

  No

  N/A

• Demonstrate how the task was performed

• Could you have done anything different to prevent the injury?

• Was there a laceration incident

  Yes

  No

  N/A

• What type of equipment or tool was used?

• We're there any know issues with the equipment/tool not functioning properly?

  Yes

  No

  N/A

• Demonstrate how the task was performed

• Could you have done anything different to prevent the injury?

  Yes

  No

  N/A

• Was there a trauma incident(slip, trip, fall, bump,etc.)

  Yes

  No

  N/A

• Did a trip, slip, bump, falling object cause the incident?

  Yes

  No

  N/A

• Was a ladder involved?

  Yes

  No

  N/A

• What type?

• Where were your feet placed on the ladder?

• Was the ladder inspected as part of the Fall Protection Program?

  Yes

  No

  N/A

• We're there any safety restraints in place?

  Yes

  No

  N/A

• Demonstrate how the task was performed

• How could this incident been prevented?

• How often do you perform this task?

• Are there any specific PPE requirements for the task and were they used?

• Was training provided for this task?

  Yes

  No

  N/A

• Were any safety mechanisms by-passed?

  Yes

  No

  N/A

• After your involvement with this incident, is there any insight you could share or preventative actions you would recommend?

CONCLUSION / ROOT CUASE

• Enter conclusions

CORRECTIVE ACTIONS REQUIRED

• Enter all correct preventative actions that will be implemented

PICTURES & DRAWINGS

• Add media

  Media

• Add drawing

  Drawing

SIGN and DATE

• Name / Signature of Employee

  Sign

• Name / Signature of Supervisor

  Sign

• Name / Signature of Department Manager

  Sign

• Name / Signature of Safety Team Lead

  Sign