accident investigation OHSR013.doc

OHSR013 Rev A

Accident / Incident Investigation Report
(Case Number: )

Company:

Department:
Location of accident/incident:

Date and time of accident/incident:
Date of report:

Type of Accident
Injury or Illness
Property Damage
Other Accidents
Injured's name

Nature of Damage:
Type:
Part of body:

Days lost:

Cost:
Employment Category:
□Regular
□Temporary
□Contractor
□Non-Employee
Length of employment:
□Less than 1 mo.
□1-5 mo.
□6mo.-5yr.
□More than 5 yr.
Estimated Cost:

Actual Cost:
Person reporting accident:
Nature of injury or illness:

Other injury’s name and nature of injury:
Object/Equipment inflicting damage:
Object/Equipment related:
Object/Equipment inflicting harm:

Person with most control of damaged object/equipment:
Person with most control of related object/equipment
Phase of employ's workday at time of injury:
□During rest period □Entering or leaving plant
□During meal period □Performing work duties
□Working overtime □other

Supervision at time of accident/incident:
□Directly supervised □Indirectly supervised□Not supervised □Supervision not feasible
Risk(Evaluation of loss potential of not corrected)
1. Loss severity potential: □Major□Serious□Minor 2.Probability of occurrence□Frequent□Occasional□Seldom
Describe how the accident/incident occurred:

Cause Analysis

Cause Analysis
Immediate causes:(what unsafe actions and conditions caused or could cause the event)

Unsafe actions:
□Operating equipment without authority □Failure to warn
□Operating at improper speed □Making safety devices inoperative
□Bypassing safety devices □Using improper or defective tools, equipment or materials
□Improper or unsafe lifting or carrying □Under influence of alcohol and/other drug
□Failure to use P.P.E □Using tools, equipment, vehicles or materials unsafely
□Failure to secure □Riding on loads, fork lifts or other lifting equipment
□Taking an unsafe position □Carelessness or recklessness
□Tampering with equipment □Horseplay
□Wrong method of working □Unsafe driving
□Serving equipment in operation □No unsafe act
□Other unsafe act, specify: _____________________________________________________________________________
____________________________________________________________________________________________________
Unsafe conditions:
□Inadequate guarding or barriers □Improper appliance or equipment
□Defective tools, equipment or materials □Inadequate, improper or Ineffective protective equipment
□Faulty electrical installation □Unsafe design or construction
□Poor housekeeping; disorder □Improper illumination
□Defective or absence of safety appliance □Improper ventilation
□Faulty machinery □Noise exposures
□Improper clothing □Radiation exposures
□High or low temperature exposures □Unsafe place of work
□Hazardous environmental conditions □No hazardous condition
□Other hazardous conditions, please specify ________________________________________________________
_______________________________________________________________________________________________ Basic Cause:

Personal factors:□Lack of skill or knowledge □Lack of capability □Stress □Fatigue □Improper motivation
□Lack of coordination □Disregard of instruction □Act of person other than injured □Bodily defects

Job factors: □Inadequate or improper supervision □Inadequate engineering □Inadequate purchasing
□Wear and tear □Inadequate maintenance □Inadequate tools/equipment□Inadequate work standards
□Abuse or misuse

Contact with: □Electricity □Heat □Cold □Radiation □Noise □Caustics □Toxic or noxious substances

Other contributing factors, please specify _________________________________________________________
_________________________________________________________________________________________________
Recommended corrective action plan. ( what should be done to prevent recurrence.)

Actions Who? When?

1. ______________________________________
______________________________________________ _____________________ ________________
______________________________________________
2. ______________________________________________
_____________ _____________________ _________________
____________________
3. ______________________________________________
______________________________________________ ______________________ _________________
______________________________________________
4. ____________________________________
_____ ______________________ _________________
_____________
5. ______________________________________________
____________________________________________ ______________________ __________________
______________________________________________
6. ______________________________________________
______________________________________________ _______________________ __________________
______________________________________________

Prepared by:
Date:
Approved by Department Manager:
Date:

Medical Comments:

Signature: ____________________ Date:_________________

Signature: Date:
Corrective Actions Follow-up

Actions Closed Date Comments

1. ________________________________________________
________________________________________________ __________________ __________________
________________________________________________
2. ________________________________________________
________________________________________________ ___________________ __________________
________________________________________________