ProSafe Consultants Ltd Incident / Accident Investigation Report

• Audit Title:

• Document No.:

• Company Name

• Conducted on:

  Date

• Prepared by:

• Location:
  Address

• Personnel as witnesses:

• Personnel as Subject experts:

Incident Details

• Location

• Investigation No #:

• Date of occurrence

  Date

• Date reported

  Date

Type of Incident. Select all that apply.

• Near Miss?

  Off

  On

• First aid?

  Off

  On

• Medical Aid?

  Off

  On

• Restricted Work?

  Off

  On

• Lost Time Injury?

  Off

  On

• Occupational Illness?

  Off

  On

• Fire or Explosion?

  Off

  On

• Service strike or Short circuit

  Off

  On

• Equipment Failure?

  Off

  On

• Property Damage?

  Off

  On

• Material or Business Loss

  Off

  On

• Motor Vehicle Accident

  Off

  On

• Threats?

  Off

  On

• Other

Injury/Loss

• What type of injury/Incident?

• Nature of Injury or Loss

• Add drawing

  Drawing

• Add media

  Media

• Was follow-up treatment and or repair required at the scene?

  Yes

  No

  N/A

Person Involved

• Persons name

• Add signature

  Sign

• Date of Birth

• Competency of those involved in relation to trade? Are certificates and or competency cards available?

  Yes

  No

  N/A

Supervision and Management

• Supervisors Name

• Was supervision suitable and sufficient

  Safe

  At Risk

  N/A

• Add media

  Media

• Are competence/qualifications/experience of supervisors/managers suitable for this type of task?

  Yes

  No

  N/A

Description

• Clearly describe how the incident occurred.Include images of area and tools etc

• Add media

  Media

• Add drawing

  Drawing

Documentation/Permits/Information

• Where method statements and risk assessments available and being referred to?

  Yes

  No

  N/A

• Do risk assessments suitably cover the work being carried out at time of the incident.

  Yes

  No

  N/A

• Where any pre-task or toolbox talks carried out in relation to this task?

  Yes

  No

  N/A

Witnesses

• Include the names and phone numbers of any witnesses to the incident. Attach witness statements or cross refer to statements.

Analysis

• Immediate causes, what acts failure to act, and conditions contributed directly to this accident?

• Basic causes, what are the contributing factors? (Job factors, personal factors)

Prevention

• What action or recommendations are required to be made to prevent recurrence?

• When are actions or recommendations required to be implemented by?

Frequency Potential

• Frequent

  Off

  On

• Probable

  Off

  On

• Occasional

  Off

  On

• Remote

  Off

  On

• Improbable

  Off

  On

Severity

• Catastrophic

  Off

  On

• Critical

  Off

  On

• Moderate

  Off

  On

• Minor

  Off

  On

Costs (if applicable).

• Estimated:

• Actual:

Conclusion

• Action required:

• Investigated by:

  Sign