Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Incident details

  • Date and time of incident;

  • Type of service encountered.

  • Name of Principal Contractor

  • 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

  • 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.

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

  • who's?

  • 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?

  • Weather conditions.

Personnel

  • Permit issued by

  • Supervisor

  • Banksman

  • Machine operator

Procedure (HSG 47 Compliance)

  • Permit to Break Ground in place?

  • Why not?

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

  • Why not?

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

  • Are copies available at the works location?

  • Why not?

  • Photos of all drawings available at the location

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

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

  • Was a CAT & Genny used?

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

  • Why not?

  • Was hand digging carried out?

  • 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)

  • Client (PC) Informed?

  • College (Apprentices)

  • HSE Informed?

Witness statements

  • Emergency Services informed?

  • Witnesses 1

  • Name and signature of the witness 1

  • Witnesses 2

  • Name and signature of the witness 2

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.

Manager/Supervisor in Charge (please sign below)

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

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.

Follow on Information.

  • Was the incident classified as Reportable under RIDDOR?

  • Name of person submitting RIDDOR report.

  • Date of RIDDOR submission.

  • Did the HSE or Police attend site?

  • 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?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.