Non Injury Service Strike Investigation

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Incident details

• Date and time of incident;

  Date

• Type of service encountered.

• Name of Principal Contractor

  Select Balfour Beatty Bellway Homes West Midlands Bellway Homes Home Counties Bromford Homes Crest Nicholson David Wilson Homes Galliford Try Jelson Homes Jessup Keepmoat Homes Kier Homes Lovell Partnership McCarthy & Stone Miller Homes M Lambe Construction Ltd Morris Homes Persimmon Homes Walton Homes William Davis St Modwen Colmore Tang

  • Balfour Beatty
  • Bellway Homes West Midlands
  • Bellway Homes Home Counties
  • Bromford Homes
  • Crest Nicholson
  • David Wilson Homes
  • Galliford Try
  • Jelson Homes
  • Jessup
  • Keepmoat Homes
  • Kier Homes
  • Lovell Partnership
  • McCarthy & Stone
  • Miller Homes
  • M Lambe Construction Ltd
  • Morris Homes
  • Persimmon Homes
  • Walton Homes
  • William Davis
  • St Modwen
  • Colmore Tang

• Site Address that the incident took place (Or other address where off site).

• Detailed description of location of incident (please be specific, plot numbers, chainage ref etc).

• Depth of service from (A) Existing ground level. (B) Proposed finished ground level.

• Sketch of location if not easily identified by plot number and/or photo

  Drawing

• Photos of various aspects of the location of the incident. Do not approach any damaged service in such a way that you may sustain Injury doing so.

  Media

• Has this incident been recorded in the accident book? Or recorded as a near miss?

  No

  Yes

• who's?

  Select M Lambe Construction Ltd Client / PC

  • M Lambe Construction Ltd
  • Client / PC

• Ensure where it has been recorded in the clients accident book that a copy is taken for our records and is sent to head office for secure storage and tracking (with injured parties consent).

• Were there any witnesses?

  No

  Yes

• Weather conditions.

  Select Clear Overcast Fog Snow Rain High Winds Extremely warm day Extremely cold day Dark (Low visibility) Below 0 degrees Celcius

  • Clear
  • Overcast
  • Fog
  • Snow
  • Rain
  • High Winds
  • Extremely warm day
  • Extremely cold day
  • Dark (Low visibility)
  • Below 0 degrees Celcius

Personnel

• Permit issued by

  Sign

• Supervisor

  Sign

• Banksman

  Sign

• Machine operator

  Sign

Procedure (HSG 47 Compliance)

• Permit to Break Ground in place?

  No

  Yes

• Why not?

• Current Service drawing referred to and seen by the people doing the work?

  No

  Yes

• Why not?

• Date of service drawings (should be less than 3 months - especially in the adopted highway)

• Are copies available at the works location?

  No

  Yes

• Why not?

  Yes

  No

  N/A

• Photos of all drawings available at the location

  Media

• Was the service which was encountered shown on service drawings?

  No

  Yes

• Was there evidence of sand or marker tape/tiles etc around the service?

  No

  Yes

• Was a CAT & Genny used?

  No

  Yes

• Photos of equipment, ensure test date information is recorded.

  Media

• Why not?

• Was hand digging carried out?

  No

  Yes

• Who hand dug?

• Why not?

Time line of what happened before and after the event.

• Set out the time line for the incident. this should include Task start time, incident time, response time (first Aid, Ambulance etc).

Who has been contacted, by who, and when?

• Service Provider informed (Service Strike)

  Yes

  No

  N/A

• Client (PC) Informed?

  Yes

  No

  N/A

• College (Apprentices)

  Yes

  No

  N/A

• HSE Informed?

  Yes

  No

  N/A

• Yes

  No

  N/A

Witness statements

• Emergency Services informed?

  Yes

  No

  N/A

• Witnesses 1

• Name and signature of the witness 1

  Sign

• Witnesses 2

• Name and signature of the witness 2

  Sign

Action: Short Term

• Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following correct safety procedures and instructions)

• What was the immediate action taken to correct the issue (how was this done):

• Who was the responsible party for correcting the issue:

Moving forwards

• Lessons Learned:

• What is the long term action needed to correct the issue:

• Please provide attachments : Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other. Which may have been taken prior to this report being compiled.

Investigation Conclusions

Person Completing Form (please sign below)

• The above report a true reflection of the Incident to the best of my knowledge.

  Sign

Manager/Supervisor in Charge (please sign below)

• The above report a true reflection of the Incident to the best of my knowledge.

  Sign

Person Accepting Liability (Where Applicable)

• Confirmation that the below accepts that a safe system of work, mandatory requirement, has not been followed which was a contributing factor in relation to the incident occurring.

  Sign

Follow on Information.

• Was the incident classified as Reportable under RIDDOR?

  Yes

  No

  N/A

• Name of person submitting RIDDOR report.

  Sign

• Date of RIDDOR submission.

  Date

• Did the HSE or Police attend site?

  Yes

  No

  N/A

• Give details including name of HSE Inspector, site representative who met them, and their findings.

• Was any action taken against M Lambe Construction Ltd in relation to this incident? If so what?