Watkins Accident Investigation Report

• Site Details

• Principle Contractor

• Site Supervisor

• Prepared by

• Conducted on

  Date

• INSTALLING A CULTURE WHERE SAFETY IS PARAMOUNT

Accident Details

• Job Name /Location

• Job No.

• Address
  Address

• Date & Time of Incident

  Date

• Exact Location of Accident / Incident

• Description of Injury / Incident

• Date & Time Work Ceased

  Date

• Date Resumed work

  Date

Details of Injured Person

• Name of person (Capital Letters, Surname first)

• Age Yrs

• Gender

• Employment Status

  Select C Watkins PAYE Contractor/Agency/Contract Services Other (Including Member of Public)

  • C Watkins PAYE
  • Contractor/Agency/Contract Services
  • Other (Including Member of Public)

• Trade or Occupation:

First Aid Given and Final Destination of Casualty

• Was First Aid Administered:

  Yes

  NO

• If Yes, First Aid Administered by:

• If yes, Details of Treatment

• Did Emergency Services attend

  Yes

  NO

• Destination of Casualty

  Return to Work

  Home

  Own GP

  Hospital Casualty

• When the accident was first reported?

• State weather conditions (include lighting) at time if accident/incident

Company / Principle Contractor / HSE Notification

• Has the Watkins Incident and Accident Level 1 Report form been completed?

  Yes

  No

  N/A

• Completed by?

• Has the Principle Contractor been notified

  Yes

  No

  N/A

• By who and who to?

• When?

  Date

• Has this been reported to the HSE by phone and F2508

  Yes

  No

  N/A

• Who Reported to HSE

• When?

  Date

About the Accident/Incident

• Type of Accident / Incident

  Select RIDDOR Specified Injury Minor Injury Dangerous Occurance Near Miss Fatality

  • RIDDOR Specified Injury
  • Minor Injury
  • Dangerous Occurance
  • Near Miss
  • Fatality

• Details of where the Accident / Incident happened

• Outline of Accident /Incident

• What staff were on site and who could have seen / heard /the accident / Incident

• Add media

  Media

Cause

• Immediate Cause - The Agent of injury or ill health (the blade, the substance, the trip hazard, the dust)

• Underlying Cause - Unsafe acts and unsafe conditions (the guard removed, the ventilation switched off)

• Root Cause - the root from which all other failings grow, often remote in time and space from the adverse event (failure to identify training needs and assess competence, low priority given to risk assessment and SSoW

Witness statements

• Witness Statement 1

• Name/Occupation

• Contact Number/Email

• Statement written by or in the words of the witness

• Signed

  Sign

• Witness Statement 2

• Name / Occupation

• Contact Number / Email

• Statement written by or in the words of the witness

• Signed

  Sign

Assessors Conclusion

• Conclusion

Assessors Sign off

• I, the undersigned, hereby certify that all information is accurate and that an actual inspection was conducted.

• Assessor Name

• Add signature

  Sign

• INSTALLING A CULTURE WHERE SAFETY IS PARAMOUNT