SIMPLE INVESTIGATION FORM

for Events graded as BLUE / GREEN

Immediate Causes of Accident/Incident:
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Underlying Causes of Accident
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Recommendations: Person Responsible Date:
1.
2.
3.
Remedial Action Taken: Person Responsible: Date:
1.
2.
3.
Manager Completing Form
Name:
______
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
Managem
ent Use:
The Causes of Accidents (examples)
1. Immediate causes:
People:
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
Place of Work:
Blocked exits
Worn furniture or floor coverings
Excessive noise
Exposure to excessive radiation/fumes/dust
Bad lighting
Poor housekeeping
Procedures:
Ignoring safety signs
Ignoring instructions/working procedures
2. Underlying Causes:
People:
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 facilities
Lack of maintenance or inspection
No induction training
Poor communication, instructions not passed on
1. Typical Topics for Recommendations
If 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.
Example:
SHORT 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 Health
LONG TERM: Implement training programme, develop policy, use alternative equipment