RCA Template LTE SHE&Risk

• Location

• Date of Accident

  Date

• Name of injured person (IP)

• Conducted on

  Date

Detail of injury / accident

• Who, what, where, when, how, why

• Initial understanding of cause of accident

• Action after initial report to Health and Safety (assist injured person, including any treatment administered,

• Name of witness and address

• Name of witness and address

• Full investigation carried out by

• Accident/incident reported under RIDDOR

  Yes

  No

• Signature of investigator

  Sign

who was involved and how?

• Was the injured person carrying out a task that is part of his/her normal duties?

  Yes

  No

  N/A

• Was the person instructed verbally or in writing and by whom?

  Yes

  No

  N/A

• Was the person trained for the task?

  Yes

  No

  N/A

• Is there an appropriate training record?

  Yes

  No

  N/A

• Was there a risk assessment for the task?

  Yes

  No

  N/A

• Was the Injured party involved aware of it?

  Yes

  No

  N/A

• Was the injured party wearing appropriate clothing and shoes for the task?

  Yes

  No

  N/A

• General comments

were there any plant/equipment/materials involved?

• Are descriptions, sketches, photographs, etc. of plant/equipment available?

  Yes

  No

  N/A

• Was the plant/equipment/material involved in good condition BEFORE/AFTER the accident?

  Yes

  No

  N/A

• Were correct tools/equipment/materials being used and in the correct manner?

  Yes

  No

  N/A

• Were machinery guards and similar protective devices adequate and effective and maintained?

  Yes

  No

  N/A

• Were appropriate notices/signage displayed?

  Yes

  No

  N/A

• General comments

Was the work environment a cause or contributing factor?

• Were the work area/premises in good condition BEFORE / AFTER the accident? Name if in any way involved.

  Yes

  No

  N/A

• Was the workplace being used as intended? Was there sufficient space for the tasks in hand?

  Yes

  No

  N/A

• Was the work area clean and tidy?

  Yes

  No

  N/A

• Were people segregated from hazardous areas/processes/machinery?

  Yes

  No

  N/A

• Were colleagues/learners/contractors (where appropriate) provided with adequate information on access/egress and the hazards within the premises?

  Yes

  No

  N/A

• General Comments

Have the following factors been considered and excluded as contributing to the cause of the accident?

• Weather

  Yes

  No

  N/A

• Temperature

  Yes

  No

  N/A

• Fumes

  Yes

  No

  N/A

• Vapour

  Yes

  No

  N/A

• Gas

  Yes

  No

  N/A

• Noise

  Yes

  No

  N/A

• Lighting (artificial or natural)

  Yes

  No

  N/A

• Premises layout and condition

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• General Comments

There is a legal requirement for Safe Systems of Work for hazardous tasks as shown by risk assessment. It is imperative that omissions or weaknesses are identified in this regard.

• Were written safe systems of work/procedures laid down for the task, whether standard or special?

  Yes

  No

  N/A

• Were the procedures/instructions followed?

  Yes

  No

  N/A

• Was the task being carried out under direct supervision if required on risk assessment?

  Yes

  No

  N/A

• Was any designated protective clothing or equipment needed and was it worn correctly, adequate and examined prior to use?

  Yes

  No

  N/A

• Were site emergency procedures e.g. first aid treatment adequate and effective?

  Yes

  No

  N/A

• General Comments

Findings

• Detail the Underlying Cause(s) of the Accident - Consider Answers Provided Above

• Detail the Root Cause of the Accident

• Investigation carried out by

• Signature

  Sign

• Date

  Date