Title Page
-
Conducted on
-
Prepared by
-
Location
Initial Details
Type of Incident
-
Personal Injury (QCF030)
-
The Managing Director, Quality, Health & Safety and Operations Manager must be contacted within 15 minutes of any Major Injury or Aircraft Incident, in the event of a ‘Fatality’ the Health & Safety Executive must be contacted by the Regional or Health & Safety Manager by ringing the Incident Contact Centre on 0845 300 9923 (opening hours Monday to Friday 8.30 am to 5 pm) or out of hours by ringing the Duty Officer on 0151 922 9235
-
Date and Time of Incident:
-
About the Accident
-
Precise Location of Incident:
-
Brief Description of Incident:
Person Investigating & Reporting the Accident
-
Name:
-
Position:
-
Base:
-
Date Form Completed:
Involved Parties
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
-
Was there any other party injured
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
-
Was there any other party injured
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
Contract
-
Full Time
-
Agency
Type of InJury
-
Has the Accident Book been completed
-
Minor Injury ( No First Aid Required)
-
Minor Injury ( First Aid Required)
-
Lost Time Injury
-
Lost Time Injury ( No Hospital Required)
-
Lost Time Injury ( Hospital Required
-
What Hospital?
-
How Long was the stay in Hospital
-
What Date did the Injured Person return to work?
-
Total days away from work
-
Major Injury/Fatality
-
Major Injury (not RIDDOR)
-
Major Injury (RIDDOR)
-
RIDDOR Reference
-
Fatality
-
Immediate report to HSE -‘Fatality’ the Health & Safety Executive must be contacted by the Regional or Health & Safety Manager by ringing the Incident Contact Centre on 0845 300 9923 (opening hours Monday to Friday 8.30 am to 5 pm) or out of hours by ringing the Duty Officer on 0151 922 9235
Equipment Involved
-
was there any equipment Involved
-
Is the Equipment owned by AAS or 3rd Party
-
Asset Number
-
Date of last Company Inspection
-
Date of last Maintenance Check
-
3rd Party Company Name
-
Contact details for 3rd Party
-
Please take Picture 3rd party Vehicle
Follow Up
-
Was a Return to Work interview completed
-
Why not?
-
Does the Injured party require ammended duties
-
Has the Employee been offered Occupational Health assistance
-
General Comments
-
Aircraft Incident (QCF034)
-
The Managing Director, Group H & S, Operations Manager must be contacted within 15 minutes of any Aircraft Incident.
-
is this an ASR, GSR, CSR or Ground Incident
-
ASR - Air Safety Report
-
Reference
-
GSR - Ground Safety Report
-
Reference
-
CSR - Customer Safety report
-
Reference
-
Ground Incident
Person Investigating & Reporting the Accident
-
Name:
-
Position:
-
Base:
-
Date and Time of Incident
Involved Parties
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
-
Was there any other party involved
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
-
Was there any other party involved
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
Contract
-
Full Time
-
Agency
Drug and Alcohol Testing
-
was the involved party tested for Drugs and Alcohol
-
What was the result
-
Why not?
Equipment Involved
-
was there any equipment Involved
-
Is the Equipment owned by AAS or 3rd Party
-
Asset Number
-
Date of last Company Inspection
-
Date of last Maintenance Check
-
3rd Party Company Name
-
Contact details for 3rd Party
-
Please take Picture 3rd party Vehicle
Airline
-
What Airline was involved
-
Flight number
-
Aircraft registration
-
Was an Airline Representative in Attendance
-
Name
-
Details of Incident
-
Was there any Damage
-
Where was the Damage
-
Details of the Damage
-
Picture with Scale of Damage
-
Schedule time of Depature
-
Actual Time of Departure
-
Delay in minutes
-
Vehicle/Equipment Incident (QCF033)
Person Investigating & Reporting the Accident
-
Name:
-
Position:
-
Base:
-
Date and Time of Incident:
Involved Parties
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
-
Was there any other party involved
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
-
Was there any other party involved
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
Contract
-
Full Time
-
Agency
Drug and Alcohol Testing
-
was the involved party tested for Drugs and Alcohol
-
What was the result
-
Why not?
Equipment Involved
-
was there any equipment Involved
-
Is the Equipment owned by AAS or 3rd Party
-
Asset Number
-
Date of last Company Inspection
-
Date of last Maintenance Check
-
Was another AAS Vehicle involved
-
Asset Number
-
Date of last Company Inspection
-
Date of last Maintenance Check
-
Was another AAS Vehicle involved
-
Asset Number
-
Date of last Company Inspection
-
Date of last Maintenance Check
-
3rd Party Company Name
-
Contact details for 3rd Party
-
Please take Picture 3rd party Vehicle
Damage
-
Give specific details of the incident and damage to vehicle
-
Take Pictures with scale of all damage
-
Environmental Incident (QCF029)
Person Investigating & Reporting the Accident
-
Name:
-
Position:
-
Base:
-
Date and time of Incident
Involved Parties
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
-
Was there any other party involved
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
-
Was there any other party involved
-
Name:
-
Age:
-
Date of Birth:
-
Home address:
-
Contact telephone number:
Contract
-
Full Time
-
Agency
Equipment Involved
-
was there any equipment Involved
-
Is the Equipment owned by AAS or 3rd Party
-
Asset Number
-
Date of last Company Inspection
-
Date of last Maintenance Check
-
Was another AAS Vehicle involved
-
Asset Number
-
Date of last Company Inspection
-
Date of last Maintenance Check
-
Was another AAS Vehicle involved
-
Asset Number
-
Date of last Company Inspection
-
Date of last Maintenance Check
-
3rd Party Company Name
-
Contact details for 3rd Party
-
Please take Picture 3rd party Vehicle
Spill Details
-
Substance Spilt
-
Is there a MSDS for the substance
-
Medium or Media into which the release occurredSpills
-
Photos Taken of Spill
-
Spill exact location
-
What were the circumstances that caused the spill
-
how much was spilt (approx in litres)
Spill Response
-
Details on Containment and Clean up
-
Were Spill Kits available and used
-
Assessment of Clean up and effort
-
Pictures taken post clean up
Investigation Details
Statements
-
Were Statements Taken
-
Why Not?
-
Name of Individual
-
ID Number
-
Statment
-
Were there any more Statements?
-
Name of Individual
-
ID Number
-
Statment
-
Were there any more Statements?
-
Name of Individual
-
ID Number
-
Statment
-
Were there any more Statements?
-
Name of Individual
-
ID Number
-
Statment
-
Were there any more Statements?
Facts
Weather
-
What was the weather at the time of incident
-
Dry
-
Wet
-
Icy
-
Snowy
-
Windy
Lighting
-
What was the condition of the lighting at time of Incident
-
Day Time
-
Night Time
-
Dawn
-
Dusk
-
Artificial Lighting
-
Interior Lighting
Behaviours and Just Culture
-
What is Just Culture?
A Just Culture is ‘an atmosphere of trust in which people are encouraged (even rewarded) for providing essential safety-related information, but in which they are also clear about where the line must be drawn between
acceptable and unacceptable behaviour’. Professor James Reason, 1997
Why have a Just Culture?
By treating people fairly, not rushing to blame and punish and considering the real-world circumstances in which your staff find themselves encourages them to greater openness and proactive reporting of hazards. If we know more about the hazards we are exposed to, then the organisation is better placed to manage its risks and implement effective mitigations. An enhanced risk picture and a safety-conscious workforce, can improve safety-risk management, reduce rework, increase operational
efficiency, and protects people and vital assets from harm. However, it must be noted that a Just Culture is not a blameless culture; people must remain accountable for their selfish or reckless behaviour.
Behaviour Identification
-
Was there a conscious, substantial and unjustifiable disregard for risk?
-
Was there malicious intent?
-
Behaviour: Sabotage or Attempted Sabotage
-
Behaviour: Recklessness
-
Were the Rules intentionally broken?
-
In the circumstance, were all applicable rules and resources available, workable, intelligent and correct
-
Was the action intended to benefit the Organisation
-
Behviour: Violation for Organisation Gain
-
Behaviour: Violation for Personal Gain
-
Was the Situation at the time outside of Standard Operations?
-
Behaviour: Exceptional Violation
-
Behaviour: Necessary Violation
-
Was the Action intended?
-
Behaviour: Mistake
-
Behaviour: Error
-
What was the Behaviour Identified
-
System - Review task for human performance issues esp. if errors occur regularly. Look at the system defences and conditions that are not optimised for human performance. What can be done to reduce the likelihood of the error or capture the error when it does happen.
Individual - Console -
System - Look at the training and education system, understand why the individual lacked the correct knowledge or did not know how to apply it in the circumstances
and address those issues.
Individual - Address through performance management and training -
System - Find and follow the goal conflicts. Assess discordance between management priorities and staff understanding. Ensure management goal priorities are clearly
and fully presented to all appropriate staff. Review processes and procedures as required.
Individual - Address through organisation-wide performance management and training. -
System - Why was this situation unexpected? Ensure that appropriate procedures, equipment and training are in place for similar future occurrences. Brainstorm other
potential but realistic unusual circumstances and develop processes and procedures for staff to deal with them and test them.
Individual - Address through training -
System - Understand the context and underlying causes, address these to prevent reoccurrence with other staff.
Individual - Manage through appropriate disciplinary action. -
System - Review the normative behaviours and the cultural drivers for those behaviours across the organisation. Address the organisation’s cultural issues.
Individual - Address through performance management and training. -
System - Understand the context and underlying causes, address these to prevent reoccurrence with other staff.
Individual - Manage through appropriate disciplinary action -
System - Understand the context and underlying causes, address these to prevent reoccurrence with other staff.
Individual - Manage through appropriate disciplinary action -
The Above instructions are suggested ways to deal with a systemic issue or a Individual Issue, you should use the same questions above and answer them as if a different member of staff is involved and see if it is the same out come this will determine what the size of the issue is and the best way to put effective corrective measures in place.
Individual
-
This Area is to ascertain if there were other casual factors that could have affected the individual
-
Is the individual Trained in the task in which they were engaged in?
-
Is there a signed and Valid Training Record (please upload a copy)
-
Was the individual carrying out work as a normal part of their duties?
-
Were they acting in accordance with Company Procedures
-
How long has the person been working for Assured Aviation Services (months)
-
Does the Individual have any known previous experience in the activity outside of AAS
-
How many years experience
Hours Worked (Working Time Directive)
-
Highlight below the shift pattern the Individual has completed the last 10 days up to and including the day of Incident
-
Day 10
-
Day 9
-
Day 8
-
Day 7
-
Day 6
-
Day 5
-
Day 4
-
Day 3
-
Day 2
-
Day 1
-
Day of Incident
-
On average how many hours were completed daily
-
Taking into the above into account do you believe Fatigue is a factor in the incident
-
Why do you believe Fatigue is not a factor?
Contributory Factors (Please tick if any of the below are applicable)
-
Behaviour
-
Please select from the list below what may have contributed?
-
This would include the following: Excess speed, Communication Failures, Spatial Misjudgement, Failure to see, Poor Judgement, Distractions, Poor Discipline, Lack of Practise in the Task, Incapacity (ill health, drugs, alcohol etc), Vandalism/Malicious Intent.
-
Physical Circumstances
-
Please select from the list below what may have contributed?
-
This could include the following: Glare/Blinding light, Walkway or Road Layout, Weather Conditions, Noise, Foreign Object Debris, Surface Conditions, Congestion, Building/Facility Layout, Inadequate Lighting, Limited Space, Signs and Markings
-
Equipment
-
Please select from the list below what may have contributed?
-
This could include the following: Defective Maintenance, Incorrect use, Unsuitable for the task, Unsafe for the task, or Design Problem
-
Organisational
-
Please select from the list below what may have contributed?
-
This could include the following: Lack of SOP's, Inadequate time to perform the task, Inadequate Supervision, Insufficient personnel, Inadequate Training
Causes
-
What is the Direct Cause (The actual or potential injury/damage inflicting contact or action)
-
What are the Influencing Pre Conditions? (Systematic factors and weaknesses that encourage at-risk behaviours or conditions)
-
What is the Root Cause?
Corrective Measures
Actions
-
What are the Immediate Corrective Measures
-
What are the Further Preventative Measures##
