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Accident Investigation Report - Sample 2
 

Accident Investigation Report - Sample 2

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    Accident Investigation Report - Sample 2 Accident Investigation Report - Sample 2 Document Transcript

    • Supervisor’s Incident Investigation Report(Sample #2)<br />EMPLOYEE NAMESOCIAL SECURITY NUMBERJOB TITLEACCIDENT/INCIDENT ADDRESS (STREETDEPARTMENTCITY, STATE, ZIP CODETELEPHONELENGTH OF TIME ON JOBSITE BUSINESSTYPE OF BUSINESSACCIDENT TYPE (select the most appropriate response)symbol 48 f " Typographic Ext" s 100 Struck againstsymbol 48 f " Typographic Ext" s 100 Fall to different levelsymbol 48 f " Typographic Ext" s 100 Contact electrical currentsymbol 48 f " Typographic Ext" s 100 Other (describe) symbol 48 f " Typographic Ext" s 100 Struck bysymbol 48 f " Typographic Ext" s 100 Slip or twist (not fall)symbol 48 f " Typographic Ext" s 100 Muscular strainsymbol 48 f " Typographic Ext" s 100 Caught in or betweensymbol 48 f " Typographic Ext" s 100 Exposure to temp. extremessymbol 48 f " Typographic Ext" s 100 Respiratory exposuresymbol 48 f " Typographic Ext" s 100 Fall on same levelsymbol 48 f " Typographic Ext" s 100 Skin exposuresymbol 48 f " Typographic Ext" s 100 Exposure to physical agents (noise, radiation, etc.)HAZARDA.Identify the behavior prior to accident/incident, describe the events such as cleaning, climbing, repairing, installing, lifting, cutting, etc.B.Identify the action that contributed to the accident, such as twist, push, crawl, stand, sit, reach, etc.CAUSE (Use the listing below as an aid in identifying the factors that contributed to the accident. (Check all that apply.)PROCEDURESCOMMUNICATIONsymbol 48 f " Typographic Ext" s 100 None developedsymbol 48 f " Typographic Ext" s 100 Insufficient planningsymbol 48 f " Typographic Ext" s 100 Developed but not followedsymbol 48 f " Typographic Ext" s 100 Breakdown in communication between workerssymbol 48 f " Typographic Ext" s 100 Developed but not trainedsymbol 48 f " Typographic Ext" s 100 Breakdown in communication between workers and supervisorssymbol 48 f " Typographic Ext" s 100 Developed but not understoodsymbol 48 f " Typographic Ext" s 100 Breakdown in communication between work teamssymbol 48 f " Typographic Ext" s 100 Developed but not accuratesymbol 48 f " Typographic Ext" s 100 Confusion after communicationsymbol 48 f " Typographic Ext" s 100 Developed but unable to followIN A HURRYHAZARDsymbol 48 f " Typographic Ext" s 100 Supervisor implied needsymbol 48 f " Typographic Ext" s 100 Customer originatedsymbol 48 f " Typographic Ext" s 100 Created by co-workersymbol 48 f " Typographic Ext" s 100 Employee perceived needsymbol 48 f " Typographic Ext" s 100 Equipment failuresymbol 48 f " Typographic Ext" s 100 Created by external factorssymbol 48 f " Typographic Ext" s 100 Friendly competitionsymbol 48 f " Typographic Ext" s 100 Rushes, deadlinessymbol 48 f " Typographic Ext" s 100 Documented but not repairedsymbol 48 f " Typographic Ext" s 100 Due to external factorssymbol 48 f " Typographic Ext" s 100 To achieve bonussymbol 48 f " Typographic Ext" s 100 Identified but not acceptedsymbol 48 f " Typographic Ext" s 100 Workload too heavysymbol 48 f " Typographic Ext" s 100 Lack of help or assistancesymbol 48 f " Typographic Ext" s 100 Unidentifiedsymbol 48 f " Typographic Ext" s 100 Lack of team worksymbol 48 f " Typographic Ext" s 100 Illnesssymbol 48 f " Typographic Ext" s 100 Repaired but deficient repairsymbol 48 f " Typographic Ext" s 100 Conditions changed without proper communicationTRAININGsymbol 48 f " Typographic Ext" s 100 Lack of documentationsymbol 48 f " Typographic Ext" s 100 Insufficient trainingsymbol 48 f " Typographic Ext" s 100 Circumstances not addressed in trainingFACILITIES/EQUIPMENTsymbol 48 f " Typographic Ext" s 100 Tools used incorrectlysymbol 48 f " Typographic Ext" s 100 Faulty equipmentsymbol 48 f " Typographic Ext" s 100 Poor designOTHER FACTORSsymbol 48 f " Typographic Ext" s 100 Corrosion/wearsymbol 48 f " Typographic Ext" s 100 Weather/temperaturesymbol 48 f " Typographic Ext" s 100 Lightsymbol 48 f " Typographic Ext" s 100 Ergonomic factorssymbol 48 f " Typographic Ext" s 100 Working long hourssymbol 48 f " Typographic Ext" s 100 Noisesymbol 48 f " Typographic Ext" s 100 Facility layoutsymbol 48 f " Typographic Ext" s 100 Physical overexertionsymbol 48 f " Typographic Ext" s 100 Atmospheresymbol 48 f " Typographic Ext" s 100 New equipmentsymbol 48 f " Typographic Ext" s 100 Personal protective equipmentsymbol 48 f " Typographic Ext" s 100 Visibilitysymbol 48 f " Typographic Ext" s 100 Change in process/materialssymbol 48 f " Typographic Ext" s 100 Improper body positionsymbol 48 f " Typographic Ext" s 100 Radiation0 Chemical<br />MAJOR CAUSE (From areas identified on the previous page, choose the major cause)symbol 48 f " Typographic Ext" s 110 Proceduressymbol 48 f " Typographic Ext" s 110 Trainingsymbol 48 f " Typographic Ext" s 110 Facilities/equipmentsymbol 48 f " Typographic Ext" s 110 Environmentsymbol 48 f " Typographic Ext" s 110 In a hurrysymbol 48 f " Typographic Ext" s 110 Communicationsymbol 48 f " Typographic Ext" s 110 Other symbol 48 f " Typographic Ext" s 110 People symbol 48 f " Typographic Ext" s 110 Materials ROOT CAUSE1.Why did the event occur? 2.Why did the behavior exist? 3.Why did the condition exist? CORRECTIVE ACTION List corrective steps to reduce potential for recurrence)1.Explain how to eliminate the hazard or task 2.Define how to engineer or design out the hazard or task 3.How would you substitute the hazard or task? 4.What type of training is needed? 5.What type of personal protective equipment is needed? Completed by Date <br />