Watson Electric Incident Investigation Report (Form 51-1.2)

Incident Investigation Report (Form 51-1.2)

• Document No.

• Conducted on

  Date

• Prepared by

• Incident Investigation Report (Form 51-1.2)

• Instructions: Use this form to document accidents resulting in an injury or illness, vehicle and equipment accidents, public and private road accidents, events involving third parties, property damage and near miss events. Use the "Root Cause Analysis" contained in section 2 on this form and other pre-planning document used to identify work tasks, potential hazards and control methods.

Incident report information: Section 1

• Type of report:

  Select occupational injury/illness equipment/vehicle property damage near miss

  • occupational injury/illness
  • equipment/vehicle
  • property damage
  • near miss

• Status of report:

  Preliminary

  Final

• Employee First - MI - Last name (persons injured, involved, driver)

• Employee identification number:

• Employee No.:

• Job Classification:

• Nationality:

• Employee address, city, state, Zip

• Employee phone cell/home:

• Employee date of birth:

• Date if incident:

  Date

• Date reported to supervisor:

  Date

• Date of hire (MM/DD/YY)

• Hourly wages?

• Type of mobile equipment or vehicle (or N/A):

• License/Equipment no.:

• Employee has Co. License?

  yes

  no

• Date issued?

• Task/Risk analysis completed?

  yes

  no

• Project number:

• Project name (Department):

• Address, City, State:

• Specific work area?

• Treatment given?

  yes

  no

  N/A

• Name of facility where treatment was given, City, State, phone and Physicians name:

• Describe type/extent of injury/illness/damage (in detail)..... Body parts, nature of injury/illness, equipment/material damaged etc. or attached photo:

• Photo

  Media

• Eye witness name, phone number cell/home or how/when to contact and name of Company (if other than Watson).

• Describe event (in detail).... Work actions occurring (or not) that lead up to the incident, equipment/material being utilized etc. or attached photo:

• Photo

  Media

• List identified Root/cause/s (see Root Causes below)

• Solutions:

• Who's responsible?

• To be completed by:

• Foreman: first name, middle name, last name

• Superintendent: first name, middle, last name.

• Project manager: first name, middle name, last name.

• Division manager: first name, middle name, last name

• Report completed by:

• Title:

• Date completed:

  Date

Root Causation Analysis: Section 2

• (Mark yes or no for all applicable questions, completing comments and recommended action portion when marked yes)

• Part 1 Equipment. was equipment/tools/materials a contributing factor? If no proceed to Part 2

  Yes

  No

  N/A

• 1.1. Did equipment/tool defects contribute? If no go to 1.2:

  yes

  no

• Comments, recommended actions:

• 1.1.1 was there an equipment/tool inspections process?

  yes

  no

• Comments, recommended actions:

• 1.1.2 was the inspection process completed as required?

  yes

  no

• Comments, recommended actions:

• 1.2 was the correct equipment/tool/material utilized? If no go to 1.3. if yes go to 1.6

  yes

  no

• 1.3 was the correct equipment/tool/material readily available?

  yes

  no

• Comments, recommended actions:

• 1.4 Did the employee know where to obtain the correct equipment/tool/material?

  yes

  no

• Comments, recommended actions:

• 1.5. Was substitute equipment/tools/material used in place of correct ones?

  yes

  no

• Comments, recommended actions:

• 1.6. List other equipment/tool/material causal factors:

  yes

  no

• List equipment/tools/material causal factors:

• Comments, recommended actions:

• Part 2 Work Environment: was the location of equipment/material/employee(s) a contributing factor? If no proceed to Part 2

  yes

  no

• 2.1 Did the location/position of equipment/material/employees contribute to the incident?

  yes

  no

• Comments, recommended actions:

• 2.2. Was the hazardous scenario recognized by the employee?

  yes

  no

• Comments, recommended actions:

• 2.3. Was the employee supposed to be in vicinity of the equipment/material?

  yes

  no

• Comments, recommended actions:

• 2.4. Was the hazardous scenario visible to the employee?

  yes

  no

• Comments, recommended actions:

• 2.5. Was there sufficient space to conduct work activities?

  yes

  no

• Comments, recommended actions:

• 2.6 were there any contributing environment conditions? (Noise levels, temperature, illumination, ventilation$

  yes

  no

• Comments, recommended actions:

• 2.7. List other environment causal factors?

• Part 3 Employee. Were the work activities conducted by the employee a contributing factor?

  yes

  no

• 3.1. Was there a written task/risk assessment or known rule for this work? If no go to 3.2:

  yes

  no

• Comments, recommended actions:

• 3.1.1. If yes did this assessment/rule anticipate the incident?

  yes

  no

• Comments, recommended actions:

• 3.1.2. If yes, did employee know the proper procedure?

  yes

  no

• Comments, recommended actions:

• 3.1.3. If yes, did the employee deviate?

  yes

  no

• Comments, recommended actions:

• 3.2. Was the employee mentally and physically capable of performing the work?<br>

  yes

  no

• Comments, recommended actions:

• 3.3. Was there a lack of required PPE utilization?

  yes

  no

• Comments, recommended actions:

• 3.3.1. If yes was appropriate PPE available?

  yes

  no

• Comments, recommended actions:

• 3.3.2. If yes did the employee know the PPE was required?

  yes

  no

• Comments, recommended actions:

• 3.3.3. If yes did the employee know how to use it?

  yes

  no

• Comments, recommended actions:

• 3.4. Was available PPE used properly?

  yes

  no

• Comments, recommended actions:

• 3.5. Was the PPE adequate?

  yes

  no

• Comments, recommended actions:

• 3.6. List other employee causal factors.

• Comments, recommended actions:

• Part 4 Supervision was the supervisory system a contributing factor? If no Root Analysis is completed.

  yes

  no

• 4.1. Was there a failure by supervision to detect a hazardous condition, deviation from safety policy or infrequently preformed task?

  yes

  no

• Comments, recommended actions:

• 4.2. Was there a failure by supervision to take corrective action for a known hazardous condition, deviation from safety policy or infrequently performed task?

  yes

  no

• Comments, recommended actions:

• 4.3. Was supervisory responsibility for the accident detection and prevention adequately defended and understood?

  yes

  no

• Comments, recommended actions:

• 4.4. Was supervision adequately trained to fulfill assigned responsibility for accident detection and prevention?

  yes

  no

• Comments, recommended actions:

• 4.5. List other management/supervisory casual factors:

  yes

  no

• Factors:

• Sample recommended action topics include, but not limited to: re-training, new/more equipment, new processes, responsibility assignments, re-do or new risk assessments, staffing sizes, work assignment loads etc. Break the topics down into action items you feel will correct this incident from recurrence.