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<br /> ACCIDENT INVESTIGATION REPORT (cont.)
<br /> Page 2 of 3
<br /> Instructions
<br /> Remember, an accident investigation is not designed to find fault or blame. It is an analysis to
<br /> determine causes that can be controlled or eliminated.
<br /> IDENTIFICATION
<br /> This section is self-explanatory. When completing the form, complete the whole section.
<br /> INCIDENT
<br /> Accident resulting in: Check appropriate box
<br /> Recordability: Check appropriate box based on:
<br /> • First Aid — Resulted in a minor injury/treatment administered by trained first aider-on
<br /> premises.
<br /> • Medical Treatment— Resulted in more serious injury/treatment administered by physician,
<br /> emergency room-off premises.
<br /> • Lost Time— Employee missed more than '/2 day from work.
<br /> Provide a brief description of the following:
<br /> • Nature of the injury— Principle physical characteristics/what happened to employee, i.e.;
<br /> sprain, contusion, burn, laceration, etc.
<br /> • Part of body— Body part directly affected by injury, i.e.; hand, fingers, arm, back, shoulder,
<br /> etc. Be specific.
<br /> • Type of accident— Brief classification of type of accident, i.e.; material handling (lifting,
<br /> pulling, pushing), contact with hot substance, slip/trip/fall, struck by/against, fall from
<br /> elevator, etc.
<br /> Description of Accident: Describe in detail what happened; where it happened; why it
<br /> happened; how it happened; what materials, equipment or conditions were involved; when it
<br /> happened, etc. Provide prompt, accurate, thorough information.
<br /> ANALYSIS
<br /> Describe all hazard(s), condition(s) or act(s) which contributed to the accident:
<br /> • Unsafe conditions— hazardous or unsafe physical condition or circumstance, i.e.; congested
<br /> production area, improperly designed workstation or tools, spill (grease, oil, water, etc.) on
<br /> the floor, inadequate lighting, poor housekeeping, defective equipment, weights handled,
<br /> poor ventilation, etc.
<br /> • Unsafe acts— Unsafe work practice, i.e.; failure to place warning signs/tags/signals, leaving
<br /> spills on floor, using defective equipment, horseplay, substance abuse, failure to use
<br /> personal protective equipment, etc.
<br /> Describe all underlying cause(s) or failure(s) which contributed to the accident:
<br /> • Underlying causes/failures— Frequency or repetition of a task, improper postures, possible
<br /> safety program deficiencies, i.e.; ineffective rules/regulations, ineffective employee training,
<br /> inadequate or unsafe job procedure, etc.
<br /> CONTROLS
<br /> Unsafe conditions and unsafe acts are symptoms of the underlying causes of accidents.
<br /> Accident investigations should strive to identify the underlying causes, and recommendations
<br /> should address corrective actions, both administrative and physical in nature. Consideration
<br /> should be given to the physical work environment, managerial controls, and individual
<br /> characteristics all of which contribute to industrial actions.
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