PAID (Post Accident Investigation Document)

• Reporting depot

  Select

• Date and Time of Incident

  Date
• Location of incident
  Address

• Conducted on

  Date

• Involved /Injured Party

• Investigating Manager

• Riddor reference (If Applicable)

• What type of incident was this?

  Personal Injury

  Near Miss

  Vehicle Collision

  FLT incident

  Aggression/violence

• Was this a Vehicle / FLT incident

  Yes

  No

• What is the vehicles Registration / serial number

• Has the Holmans report been completed

• Has the MVIR form been completed

• Is there any photos of the damge/ location

  Yes

  No

• Was a third party involved

  Yes

  No

• Third Party Details & Vehicle Reg

• Was a third party involved

  Yes

  No

• Third party details & Vehicel Reg

• Name

• Employee/Agency etc

  Employee

  Contractor

  Visitor

  Agency

• Home Address

• Occupation

• Length of Service

• Date of Birth

  Date

• Telephone Number

• Was an injury sustained

  Yes

  No

• What injury has been sustained

• Add drawing

  Drawing

• First aid Given

  Yes

  No

• Name of First Aider

• Treatment Given

• First aider statement

• Signed

  Sign

Witnesses

• Was there any witnesses

  Yes

  No
Witnesses

• Name of Witness

• Witness statement

• Witness Signature

  Sign

• Details of Incident; Factual statement of what happened and where?

• Was any plant/equipment/property etc damaged

  Yes

  No

• Details of Plant/equipment/property damage etc - Include photos where possible

• What was the management/emergency response to the incident:

Evidence

• CCTV

  Yes

  No

• Risk Assessment

  Yes

  No

• List applicable Risk Assessment numbers

• Safe System of Work

  Yes

  No

• List applicable Safe Systems of Work numbers

• Inspection records

  Yes

  No

• Was a D&A test required

  Yes

  No

• What was the result

• Evidence: Other (Comment below)

• Has a safety-first call been arranged

  Yes

  No

• What Date/Time

• Immediate Cause - The agent of injury or ill health (the blade, the substance, the dust, the wet floor, etc.);

• Underlying cause - Unsafe acts and unsafe conditions (the guard removed; the ventilation switched off, failure to clean up, leaking roof, etc.)

• Root Cause(s) - The failure from which all other failings grow (e.g. failure to identify training needs and assess competence, low priority given to risk assessment, improper maintenance systems, etc).

Human Factors

• Did a Human Error occur?

  Yes

  No

• Did the individual violate (break a rule) or was it a genuine error?

  Select

• Was the error skill based (Lack of knowledge or training) or was is a mistake against a known process?

  Select

• Was the Error a Slip of a known action or a lapse of memory

  Select

• Was this a rule based mistake or a knowledge based mistake

  Select

• Was this a routine (Regular) violation of a process, A situational violation (A violation which occurs during a set situation) or a Exceptional (Out of the ordinary, unique violation)

  Select