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: