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SIMPLE INVESTIGATION FORM

for Events graded as BLUE / GREEN

Immediate Causes of Accident/Incident:

_______________________________________________________________________

_______________________________________________________________________

______________________________________________________________________________________________________________________________________________

_______________________

Underlying Causes of Accident

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

_______________

Recommendations: Person Responsible Date:

1.

2.

3.

Remedial Action Taken: Person Responsible: Date:

1.

2.

3.

Manager Completing FormName:

______

Signature: _______________________

Designation/Role:_________________

Date Started Investigation:__________

Date Complete:__________________

Following Departments Informed:Service Manager: Date:

HR: Date:

Risk, H&S Advisor Date:

Further Investigation Required:YES/NO

Re-grading after investigation Green/Yellow /Red

Investigation Complete:_________YES/NO Date:________________Risk

Management Use:

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The Causes of Accidents (examples)

. Immediate causes:

eople:

Using equipment without authority

Cutting corners

Failure to use P.P.E properly

Removal of safety equipment i.e. guards

Incorrect behaviour

Devices/Equipment:

No guards

Device unfit for purpose

Equipment wear and tear

Inadequately constructed

lace of Work:

Blocked exits

Worn furniture or floor coverings

Excessive noise

Exposure to excessive radiation/fumes/dust

Bad lighting

Poor housekeeping

rocedures:

Ignoring safety signs

Ignoring instructions/working procedures

. Underlying Causes:

eople:

Not physically capable

Sensory disability e.g. hearing, sight

poor co-ordination

Under stress

Work overload

Lack of experience or training

Abuse or misuse of equipment

Work:

Lack of supervision

Inadequate or no risk assessment

Inadequate design of equipment

Inadequate storage facilitiesLack of maintenance or inspection

No induction training

Poor communication, instructions not passed on

. Typical Topics for Recommendations

f possible keep to a maximum of 3 recommendations as more is usually overburdening on the system. Also draft

short, medium and long term recommendations to keep the process moving.

xample:

HORT TERM: Display safety signs i.e. Fire exits, Wet floors, remove equipment from service

MEDIUM TERM: Prepare and use risk assessments, procedures, site rules, refer to Occupational HealthONG TERM: Implement training programme, develop policy, use alternative equipment