Easy assignments - Need in 6-8 Hours.Safety Management Systems

Accident Investigation Form

General Report Details:

Injured/Deceased Person(s):

· Employee

· Non-employee

Address:

S.S.N.:

D.O.B.:

Date of Hire:

Emergency Contact Notified:

Brief Description of Injuries:

Involved Persons: Include Name, Address, Phone #, DOB, ID#

1.

· Employee

· Non-employee

2.

· Employee

· Non-employee

3.

· Employee

· Non-employee

4.

· Employee

· Non-employee

5.

· Employee

· Non-employee

6.

· Employee

· Non-employee

7.

· Employee

· Non-employee

Incident Date:

Incident Time:

Employee Occupation:

Report Date:

Report Time:

Shift:

Employee Dept:

Workstation:

Incident Location:

Witness(s):see attached witness statement form(s)

Was First Aid administered:

Who provided First Aid:

Was the injured or deceased removed:

Where to:

By whom:

Environmental Conditions: check all that apply

Incident/ Illness Description:

Was there property damage:

Was there production time lost:

Estimated Time Lost: Hrs

What was damaged: (item, est. cost, Skew #)

1. .

2. .

3. .

4. .

Did the injured party receive training:

Date of most recent training:

Hours at work prior to injury/illness:

Time of last break:

Job/ Task Details:

Core Activity:

(Job being performed at time of injury/illness)

· Asbestos Removal

· Assembly Operations

· Blasting

· Blending

· Brazing

· Business (meetings, travel, event)

· Cafeteria Operations

· Chemical Production Operations

· Cleaning Operations

· Compounding

· Compressed Gas Cylinders Operations

· Confined Space Operations

· Construction

· Customer Assistance

· Cutting Operations

· Demolition

· Disassembly Operations

· Electrical Work

· Elevated Work Operations

· Equipment De-installation

· Equipment Installation

· Equipment Operation

· Extrusion

· Forming

· Housekeeping

· Inspecting

· Laboratory Operations

· Ladder Operations

· Lifting

· Loading/ Unloading

· Machining

· Maintenance

· Material Handling

· Non-specific Site Activity

· Office Work

· Packaging

· Pipeline Operations

· Plating

· Press Operations

· Railcar Movement

· Repair

· Resident Assistance

· Security/ Emergency Response Operations

· Shipping/ Receiving

· Surface Cleaning

· Surface Coating

· Testing

· Vehicle Operations

· Vessel Inserting/ Purging

· Waste Management

· Welding

· Woodworking

Job Activity Type:

How Normal and frequently was the job being performed at the time of the injury/ illness relative to the employees job responsibilities?

· Not normal

· Normal and routine

· Normal but not routine

Time on Job/ Task:

How long has the employee been in the job being performed at the time of injury/ illness?

Years of Service:

How long has the employee been in the company at the time of injury/ illness?

If the injury/illness involved motor vehicles such as company cars or fork-trucks, please DRAW THE INCIDENT. Indicate North with an arrow. NOT TO SCALE .

Immediate Cause:

Unsafe Condition:

Select principal factor that directly preceded and resulted in the injury/ illness

· Administrative workplace control not followed

· Allergic Reaction

· Congested or tight space

· Defective/ worn/ maladjusted vehicle

· Defective/ worn/ maladjusted equipment

· Ergonomically inadequate workstation or rotation

· Excessive noise/ vibration/ light; inadequate light

· Exposure to animals/ insects/ plants

· Exposure to bloodborne pathogens

· Inadequate guards, barriers, or warning system

· Exposure to extreme weather

· Exposure to ionizing radiation

· Exposure to non-ionizing radiation

· Exposure to smoke/ dust/ fumes/ or vapors

· Fire or explosion hazard

· Guest/ visitor contact

· High or low air temperature

· High or low surface temperature

· Housekeeping, unsafe placement, slip/ trip hazards

· Improper fitting parts, materials, fasteners

· Inadequate time allotted to task

· Inadequate/ faulty/ no PPE assigned or available

· Loss of utilities

· Overpressure/ underpressure

· Sharp edge on part, workstation, or equipment

· Spilled/ splashed chemicals or leaking containers

· Unsafe food or drink

· Wet, icy, snowy road or walkway

Unsafe Act:

Select principal factor that directly preceded and resulted in the injury/ illness

· Ascending/ descending stairs improperly

· Assigned rotation or rest intervals not used

· Did not heed warning signals, lights, sounds

· Employee awareness/ attentiveness

· Employee in danger zone/ line of fire

· Equipment/ tool used improperly

· Failed to execute LOTO

· Failed to use proper fall protection

· Failed to warn or barricade

· Horseplay or distracting behavior

· Improper force/ posture/ position

· Improper lifting

· Improper loading

· Improperly placed/ secured mats, tools, furniture

· Inadequate check for obstacles in vehicle path

· Inadequate clearance for safely stopping vehicle

· Inattention to established procedures

· Operated vehicle improperly

· Proper PPE not used for task

· Removed or disabled safety devices or guards

· Used area not intended for walking/working

· Wrong/ defective item used

Root Cause:

Job Factor:

Select principal factor that directly preceded and resulted in the injury/ illness

· Inadequate communication

· Inadequate control system setup or failure

· Inadequate engineering

· Inadequate inspection/ auditing

· Inadequate job planning, instruction, supervision

· Inadequate mechanical integrity/ maintenance management

· Inadequate procedures/ work instruction/ work standards

· Inadequate sourcing/ supplier control

· Inadequate maintained tools/ equipment

· Knowing misuse or abuse

· Work environment not controlled

Personal Factor:

Select principal underlying personal factor that resulted in the injury/ illness

· Difficult for employee to execute

· Human error

· Lack of knowledge or skill

· Not under direct control of employee

· Physical capability

· Physical or psychological stress

Descriptive Root Cause:

Describe in detail, any specifics of the root cause analysis

Management Systems:

Principal Management System:

Select principal applicable site management system whose failure contributed to the case and/ or can prevent reoccurrence

· Air

· Chemical control

· Chemical management

· Contractor safety

· Emergency preparedness & Fire Prevention

· Ergonomics

· Expectations & Performance appraisals

· General environmental

· Hazard analysis & Regulatory Compliance

· High risk Operations

· Housekeeping & Inspections

· Incident Reporting, Investigation, & Follow up

· Industrial hygiene

· Lockout Tag out

· Management of Change

· Medical Services

· Motor Vehicle Safety

· Personal Protective Equipment

· Preventive Maintenance

· Process Safety Management

·

· Program Evaluation

· Safety Risk Assessment

· Site health & Safety Policy

· Training

· Waste

· Waste & materials Shipping

· Water

Follow Up:

Corrective Actions:

Closure Comments:

Follow Up Status

· Open

· Closed

Closure Date: