Determine Root Cause Do this investigation with an open mind, and assume the readers know nothing about the Accident Worker Accident Scene Focus on the facts, NOT opinions Provide sufficient details, be clear and concise

PEOPLE

  • We're shortcuts avoided that could possibly be a safety issue

  • We're employees wearing proper PPE

  • Overextension / working on a ladder etc.

PROCESS

  • Was there adequate supervision

  • We're policies being enforced

  • Had the employee had adequate trading for the job

  • We're the expectations clear, and understood

  • Act or condition not covered please explain below

Equiptment

  • We're all tools and equipment safe to use

  • Was the proper machine being used on the job

Enviroment

  • Was there proper lighting

  • We're the employees given a realistic deadline

Attach supporting materials to your report. Photos / Diagrams

  • Add media

  • Add drawing

Background questions to know the answers to

  • Had this risk been reported before

  • Was problem corrected before, if so by who

  • Have other events occurred at this site

  • Has this employee been involved in other events

  • Have other events occurred with this supervisor

  • Explain in detail why this event happened

  • What initiated the event

  • List series of events that led to this event

  • What was the last event before this accident

Incident Type

  • Serious

  • Major/Recordable

  • First Aid Only

  • Near Miss

This event was the result of

The above must be corrected by the following

CORRECTION MUST BE COMPLETED

  • Before further use

  • Within 3 days

  • At earliest opportunity

Larry Richardson, Vice President Safety and Risk Control Watson electrical Construction, LLC 1500 Charleston Street, SE Wilson North Carolina 27893 252-237-7511 ext. 213 252-230-6871 cell

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.