SHEQ Incident / Accident Investigation

• Contract

• Works Package

• Location

• Date of Accident / Incident

  Date

• Prepared by

• Site Supervisor (PICW)

• Additional personnel on site

• Brief description of work activity

• Client

• Principle Contractor

• Executive Summary

Initial Report

• WHO - Who was involved? Injured Parties, Witnesses, PICW, Roles

• WHAT - What happened? Describe the event, incident type etc

• WHEN - When did it happen? Date, time, day, and what phase of the works

• WHERE - Specific location on site, what3words. Proximity to other works or high-risk area?

• WHY - Why did it happen? SSoW followed? Adequate RAMS, training, supervision, behaviours?

• HOW - How did it lead to injury/damage? Sequence of failure, controls fail or not exist?

• OTHER INFO - Work environment, time pressure, job complexity, layout etc

• CRITICAL GAPS - What do you not know but need to know?

• Site Photos

  Yes

  No

  N/A

• Inductions

  Yes

  No

  N/A

• Training / Competency Records

  Yes

  No

  N/A

• Daily Risk Assessment

  Yes

  No

  N/A

• MSRA for works

  Yes

  No

  N/A

• Permit(s) to Work

  Yes

  No

  N/A

• LOLER & PUWER

  Yes

  No

  N/A

• Thorough Examination Records

  Yes

  No

  N/A

• Daily Plant / HGV / Vehicle Inspections

  Yes

  No

  N/A

• CAT & Genny calibration records

  Yes

  No

  N/A

• COSHH / MSDS

  Yes

  No

  N/A

• Lift Plan

  Yes

  No

  N/A

• Service Maps

  Yes

  No

  N/A

• Insurance Documents

  Yes

  No

  N/A

• Witness Statements

  Yes

  No

  N/A

• 3rd Party Witness Statements

  Yes

  No

  N/A

• First Aid Equipment used

  Yes

  No

  N/A

• RIDDOR reported

  Yes

  No

  N/A

• Confirm incident communicated to JV SHEQ / DIRECTORS / CLIENT / HSENI

  Yes

  No

  N/A

• Time line of events

• Was there anything unusual or different about the working conditions?

• Were there adequate safe working procedures and were they followed?

• What injuries or ill health effects, if any, were caused?

• If there was an injury, how did it occur and what caused it?

• Was the risk known? If so, why wasn’t it controlled? If not, why not?

• Did the organisation and arrangement of the work influence the adverse event?

• Was maintenance and cleaning sufficient? If not, explain why not.

• Were the people involved competent and suitable?

• Did the workplace layout influence the adverse event?

• Did the nature or shape of the materials influence the adverse event?

• Did difficulties using the plant and equipment influence the adverse event?

• Was the safety equipment sufficient?

• Single Pont of Failure - Was any single person, step, or control critical to preventing the event?

• Did other conditions influence the adverse event?

• What was the immediate cause - What allowed the event to happen? • Unsafe act or condition • Plant failure, lapse, non-compliance

• Underlying cause - Why did the condition exist? • Training gaps, fatigue, supervision failure • Missing or inadequate RAMS / communication

• Root cause - What organisational factors enabled this? • Weak safety culture, planning failure • Resources, leadership, contractor management • Unclear responsibilities or permit systems

• What happened and why? Keep asking why / so what?

• Are human failings (errors and violations) identified as a contributory factor?<br>

  Yes

  No

  N/A

• Skill-based errors?<br>• Slip - Unintended action during a routine task; execution error.<br>• Lapse - Missed or forgotten step due to memory failure.

  Yes

  No

  N/A

• Mistake?<br>• Rule-based mistake - Applies the wrong known rule to a familiar situation.<br>• Knowledge-based mistake - No rule exists; wrong decision made from first principles.

  Yes

  No

  N/A

• Violation?<br>• Deliberate rule-breaking to save time, effort, or out of habit.

  Yes

  No

  N/A

Latent Failures / Systemic Weaknesses

• Were there any organisational, design, planning or cultural weaknesses that contributed to this event?

  Yes

  No

  N/A

• Would this have occurred in a different high-performing team or under different leadership?

  Yes

  No

  N/A

• What was "normalised" that shouldn’t be?

  Yes

  No

  N/A

• What risk control measures are needed/recommended? Consider Hierarchy of Controls

• Do similar risks exist elsewhere? If so, what and where & what steps can be taken to mitigate it?

  Yes

  No

  N/A

• Have similar adverse events happened before? Give details.

  Yes

  No

  N/A

• Which risk control measures should be implemented in the short term?

• Which risk control measures should be implemented in the long term?

• Which risk assessments and RAMS / SSoW need to be reviewed and updated?

• Have the details of adverse event and the investigation findings been recorded and analysed?

  Yes

  No

  N/A

• Are there any trends or common causes which suggest the need for further investigation?

  Yes

  No

  N/A

• What did the adverse event cost? • Time, Resources, Financial Impact, Human Harm or Life Loss