WellMax Accident/incident investigation report

• Report type

  Select Initial report Interim report Full Report

  • Initial report
  • Interim report
  • Full Report

• Client

• Site
  Address

• Investigation undertaken by

• Signature

  Sign

• Position

• Date & time

  Date

• Date and time of the incident?

  Date

• Weather conditions?

• Emergency services called?

  Yes

  No

  N/A

• Photographs taken?

  Yes

  No

  N/A
Injured Person/Party(s)?

• Name?

• Position?

• Company?

Project Manager?

• Name?

• Company?

Site Supervisor?

• Name?

• Company?

Persons informed?

• Name?

• Position?

• Company?

Photographs

• Photographs taken?

  Yes

  No

  N/A

Exact location of incident?

• Where did the incident take place?

What happened?

• Brief description?

Nature of Incident

• Category?

  Select Fatality Reportable injury (RIDDOR) Absence >7-days (RIDDOR) Dangerous occurrence Near Miss Other? (injuries, time loss, <7-day absence, etc.)

  • Fatality
  • Reportable injury (RIDDOR)
  • Absence >7-days (RIDDOR)
  • Dangerous occurrence
  • Near Miss
  • Other? (injuries, time loss, <7-day absence, etc.)

• Injured person/Party(s)?

• Other comments (explanation)

Incident Summary

• Current Status

Timeline of events / Key actions post incident

• Date?

  Date

• Event (Basic description)

Details of injured person(s)

• Name?

• Company?

• Position?

• Contact details?

  Yes

  No

  N/A

• Home phone number?

• Mobile phone number?

• Email?

• Statement obtained?

  Yes

  No

  N/A

• Type/nature of injuries sustained (If known)

Other Parties Involved/witnesses

• Name?

• Company?

• Position?

• Contact details?

  Yes

  No

  N/A

• Home Phone Number?

• Mobile Phone Number?

• Email?

• Statement obtained?

  Yes

  No

  N/A

Type / Nature of works?

• What was the type and nature of works being undertaken at time of incident?

Other important details / facts?

• State known facts and details

Current status of incident area

• Principal actions taken

Root and underlying cause

• How and why did the incident happen?

Post incident Management

• What actions were taken?

Key photographs of incident site & appendices

• undefined

Key documentation / Records

• Photos taken

Communication of the incident

• How was the incident communicated, and to who?

Basic risk factors: To assess an incident requires understanding not only what happened, but also why it happened. Any incident occurs because protective barriers fail. These barriers can fail when people make mistakes (the ‘active failure’), which are more likely with a ‘precondition’ that was encouraged by a ‘latent failure’, which was established by the ‘organisation environment’ (the basic risk factors) The basic risk factors below should be identified for inclusion in report. Detail any comments/findings from the investigation. Tick all applicable BRF's that had an influence/impact on the incident, complete with an explanation.

• Design? (Definition: Ergonomically poorly designed equipment that is user unfriendly)

• Error enforcing condition? (Definition: Unsuitable physical conditions and other influences (stress, tiredness/fatigue) that have a disadvantageous effect on human functioning)

• Tools and equipment? (Definition: Poor quality, condition, suitability of materials, tools, equipment)

• Housekeeping? (No or insufficient attention given to keeping the working area clean and tidy)

• Maintenance management? (No or inadequate performance of maintenance tasks and repairs)

• Procedures? (Insufficient quality or availability of procedures, specifications, guidelines, instructions and manuals)

• Training? (Insufficient competence amongst employees or subcontractors, incorrect PPE)

• Communication? (Ineffective communication between the involved parties)

• Incompatibility of goals? (Safety verses production, deadlines, incentives, political, social or individual goals)

• Organisation? (Shortcomings in structure, philosophy, management of the works)

• Defenses (No or insufficient protection (PPE) of people, material and environment against the consequences of operational disturbance)

Learnings & recommendations

• Learning

• Recommendations

• Actions carried out and planned

• Conclusion

Compiled by:

• Name

• Signature

  Sign

• Company

• Position

• Contact Telephone Number

• Email