TKL-F-14a - Accident & Adverse Event Report and Investigation Form

Title Page

Site conducted
Conducted on
Prepared by
Location

Part 1 Overview

Ref No:
The purpose of this form is to record all adverse events. The term accident is used where injury or ill health occurs. The term incident includes near-misses and undesired circumstances, where there is the potential for injury. Part 1 should be filled out immediately by the manager or supervisor for the work activity involved. Part 2 should be completed by the person responsible for health and safety. Part 3 should be completed, where appropriate, by the investigation team. Part 4 should be completed by the investigating team, together with managers who have the authority to take decisions. When completing Parts 2, 3 and 4 refer to the guidance under ‘A step by step guide to health and safety investigations’
Reported by:
Date/Time of adverse event:
Type of incident
Brief details (what, where, when, who, how and emergency measures taken):
Give details:
Forwarded to:
Date & Time:

Part 2: Initial assessment (to be carried out by the person responsible for health and safety)

Type of event
Actual/potential for harm
Please indicate Y/N as applicable

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RIDDOR Reportable?
Date/Time Reported
Entry into accident book
Date entered
Reference no
Type of event
Initial Assessment carried out by:
Date:
Further investigation required?
Priority
For investigation by:

Part 3: Investigation information gathering

1 Where and when did the adverse event happen?
2 Who was injured/suffered ill health or was otherwise involved with the adverse event?
3 How did the adverse event happen? (Note any equipment involved)
4 What activities were being carried out at the time?
5 Was there anything unusual or different about the working conditions?
6 Were there adequate safe working procedures and were they followed?
What was the reason there was not safe working procedures in place and why weren't they followed?
7 What injuries or ill health effects, if any, were caused?
8 If there was an injury, how did it occur and what caused it?
9 Was the risk known? If so, why wasn’t it controlled? If not, why not?
10 Did the organisation and arrangement of the work influence the adverse event?
11 Was maintenance and cleaning sufficient? If not, explain why not
12 Were the people involved competent and suitable?
13 Did the workplace layout influence the adverse event?
What influence did it have on the event?
14 Did the nature or shape of the materials influence the adverse event?
Comment:
15 Did difficulties using the plant and equipment influence the adverse event?
Comment:
16 Was the safety equipment sufficient?
17 Did other conditions influence the adverse event?
18 What were the immediate, underlying and root causes? (Use the 5 Why method)
Because:
19 What risk control measures are needed/recommended?
Recommendations
20 Do similar risks exist elsewhere? If so, what and where?
Please state:
21 Have similar adverse events happened before? Give details
Give details:

Part 4: The Risk Control Action Plan

22 Which risk control measures should be implemented in the long and short term?
Control Measure
Completion Date
Person Responsible
23 Which risk assessments and safe working procedures need to be reviewed and updated?

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Name of risk assessment safe working procedure
Completion Date
Person Responsible
24 Have the details of the adverse event and the investigation findings been recorded and analysed? Are there any trends or common causes which suggest the need for further investigation? What did the adverse event cost?
Please state details recorded & analysed:
Please state trends or common causes:
Please state adverse event cost:
25 Signed on behalf of the investigation team