accident investigation OHSR013.doc

OHSR013 Rev AAccident / Incident Investigation Report(Case Number: )Company:Department:Location of accident/incident:Date and time of accident/incident:Date of report:Type of AccidentInjury or IllnessProperty DamageOther AccidentsInjureds nameNature of Damage:Type:Part of body:Days lost:Cost:Employment Category:RegularTemporaryContractorNon-EmployeeLength 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 injurys 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/equipmentPhase of employs workday at time of injury:During rest period Entering or leaving plantDuring meal period Performing work dutiesWorking overtime otherSupervision at time of accident/incident:Directly supervised Indirectly supervisedNot supervised Supervision not feasibleRisk(Evaluation of loss potential of not corrected)1. Loss severity potential: MajorSeriousMinor 2.Probability of occurrenceFrequentOccasionalSeldomDescribe how the accident/incident occurred: Cause AnalysisCause AnalysisImmediate 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 inoperativeBypassing safety devices Using improper or defective tools, equipment or materialsImproper or unsafe lifting or carrying Under influence of alcohol and/other drugFailure to use P.P.E Using tools, equipment, vehicles or materials unsafelyFailure to secure Riding on loads, fork lifts or other lifting equipmentTaking an unsafe position Carelessness or recklessnessTampering with equipment HorseplayWrong method of working Unsafe driving Serving equipment in operation No unsafe actOther unsafe act, specify: _ _Unsafe conditions:Inadequate guarding or barriers Improper appliance or equipmentDefective tools, equipment or materials Inadequate, improper or Ineffective protective equipmentFaulty electrical installation Unsafe design or constructionPoor housekeeping; disorder Improper illuminationDefective or absence of safety appliance Improper ventilationFaulty machinery Noise exposuresImproper clothing Radiation exposuresHigh or low temperature exposures Unsafe place of workHazardous 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 motivationLack of coordination Disregard of instruction Act of person other than injured Bodily defectsJob factors: Inadequate or improper supervision Inadequate engineering Inadequate purchasing Wear and tear Inadequate maintenance Inadequate tools/equipmentInadequate work standards Abuse or misuse Contact with: Electricity Heat Cold Radiation Noise Caustics Toxic or noxious substancesOther 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:_ Signatur