05e Formal Inves Report

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UNITED ATTACHMENT E
F O R M A L A C C I D E N T I N V E S T I G AT I O N R E P O RT
(MANAGEMENT)
PROJECT / SITE NAME: DATE:

EXACT LOCATION OF ACCIDENT: DATE OF OCCURRENCE:
CITY: STATE: TIME OF OCCURRENCE:
SUPERVISOR’S TITLE:
REPORT PREPARED BY: SITE EMERGENCY

PLAN IN PLACE YES NO
PROJECT MANAGER OR DESIGNEE:
DESCRIBE HOW INDICENT OCCURRED, ACTIVITY, AUTHORITY, JOB METHOD, ETC.
D
E
S
C
R
I
P
T
I
O
N
INJURED: SOCIAL SECURITY NO.
ADDRESS: CITY: STATE: ZIP:
NATURE OF INJURY / ILLNESS:
B ODY PART: SOURCE OF INJURY:
PREVIOUS INJURIES
ACTIVITY AT TIME OF ACCIDENT
NAME / ADDRESS OF DOCTOR
NAME / ADDRESS OF HOSPITAL
PROPERTY DAMAGE
/conversion/tmp/scratch/440670951.doc
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UNITED ATTACHMENT E
MODEL / SERIAL NUMBER:
NATURE OF DAMAGE
SOURCE OF DAMAGE
IMMEDIATE CAUSES. WHAT SUBSTANDARD ACTS AND CONDITIONS CONTRIBUTED DIRECTLY TO THIS INCIDENT
A
N
A
L WHAT PERSONAL FACTORS WERE BASIC CAUSES OF THIS INCIDENT? EXPLAIN.
Y
S LACK OF KNOWLEDGE OR SKILL IMPROPER MOTIVATION PHYSICAL OR MENTAL PROBLEMS
I INADEQUATE PLANNING WILLFUL DEVIATION
S
O
F
C
A WHAT JOB FACTORS WERE BASIC CAUSES OF THIS INCIDENT? EXPLAIN.
U
INADEQUATE WORK STANDARDS INADEQUATE DESIGN INADEQUATE MAINTENANCE
S ABUSE OR MISUSE INADEQUATE INSPECTION INADEQUATE PURCHASING STANDARDS
E
S
WHAT ARE THE REASONS FOR THE ACTIVITY BEING OUT OF CONTROL? EXPLAIN.
INADEQUATE PROGRAM INADEQUATE PROGRAM STANDARDS INADEQUATE COMPLIANCE WITH STANDARDS
POTENTIAL LOSS IF NOT CORRECTED:
LOSS SEVERITY POTENTIAL: PROBABILITY OF RECURRENCE:

MAJOR SERIOUS MINOR FREQUENT OCCASIONAL SELDOM
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UNITED ATTACHMENT E
TYPE OF INCIDENT:
CAUGHT IN CAUGHT BETWEEN STRUCK BY FALL SAME LEVEL

EXPOSURE TO CAUGHT ON STRUCK AGAINST STRAIN / STRESS
FALL TO LOWER CONTACT WITH
ACTION PLAN: WHAT HAS OR SHOULD BE DONE TO PREVENT SIMILAR LOSS?

P _________________________________________________________________________________________
R
_________________________________________________________________________________________
E
V _________________________________________________________________________________________
E _________________________________________________________________________________________
N
_________________________________________________________________________________________
T
I _________________________________________________________________________________________
O _________________________________________________________________________________________
N
_________________________________________________________________________________________
_____
R RECOMMENDATIONS FOR IMPROVEMENTS OR TO PREVENT RECURRENCE OF ACCIDENT . TRANSFER TO ACTION
REGISTER . F EEDBACK ON COMPLETION .
E RECOMMENDATION ONE
C
O
M ASSIGNED TO: COMPLETED BY:
M
E RECOMMENDATION TWO
N
D
A
T
ASSIGNED TO: COMPLETED BY:
I
O
RECOMMENDATION THREE
N
S
ASSIGNED TO: COMPLETED BY:
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UNITED ATTACHMENT E
INVESTIGATION REPORT
PERSONAL PROTECTIVE EQUIPMENT USE:
ITEM
FUNCTION OR REQUIRED AVAILABLE USED NEEDED OTHER
MODEL
HEAD P ROTECTION
EYE P ROTECTION
RESPIRATORY P ROTECTION
EAR P ROTECTION
B ODY RESTRAINT
B ODY CLOTHING
F OOT P ROTECTION
GLOVES
F IRE / HEAT PROTECTION
OTHER
INFLUENCING FACTORS: (C=CONTRIBUTED; N=NOT A FACTOR; P=PRESENT B UT NOT SIGNIFICANT)

SUPERVISORY: C N P
INADEQUATE TRAINING
INADEQUATE INSTRUCTIONS
INADEQUATE PLANNING
TASK OVERLOADING
USED UNQUALIFIED PEOPLE
ALLOWED INSUFFICIENT TIME
INADEQUATE REQUESTED EQUIPMENT
WRITTEN INSTRUCTIONS NOT USED
PROPER TOOLS NOT PROVIDED
LACK OF ORDER
INADEQUATE JOB ANALYSIS
INADEQUATE JOB OBSERVATION
PROTECTIVE EQUIPMENT NOT PROVIDED
COMMUNICATIONS:
NO INSTRUCTIONS / FEEDBACK
MISINTERPRETATION
DISRUPTED
NOISE INTERFERENCE
LANGUAGE B ARRIER
USED ONLY ONE MODE
ENVIRONMENTAL:
HEAT
COLD
NOISE
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UNITED ATTACHMENT E
ENVIRONMENTAL (CONT’D): C N P
VIBRATION
PRESSURE LOSS / CHANGE
SMOKE FUMES
WIND DRAFT / AIR BLAST
ACCELERATION / DECELERATION
WEATHER
PSYCHOLOGICAL:
HUMAN DESIGN FACTORS
PERCEPTUAL ILLUSION
PERCEPTUAL DISTORTION
HABIT INTERFERENCE
MISINTERPRETATION
PREOCCUPATION
DISTRACTION
ATTENTION FIXATION
INATTENTION
B OREDOM
APPREHENSION
OVERCONFIDENCE
EXCESSIVE MOTIVATION TO PRODUCE
PANIC
PHYSIOLOGICAL:
FATIGUE CHRONIC
FATIGUE ACUTE (TEMPORARY)
TOXIC POISONING
HYPERVENTILATION
DRUG OR MEDICATION
ALCOHOL
HANGOVER
HYPOGLYCEMIA (LOW B LOOD SUGAR)
DIZZINESS
NAUSEA
OTHER ILLNESS:__________________________________________
ADDITIONAL NOTES
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UNITED ATTACHMENT E
CONTINUATION SHEET
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UNITED ATTACHMENT E
FO R M A L A C C ID E N T IN V E S T IG AT I O N
PHOTO LOG (MANAGEMENT)
DATE OF INVESTIGATION: TIME OF INVESTIGATION:
NOTE: DO NOT USE THE CAMERA NUMBERING SYSTEM WHEN USING A 35MM CAMERA. START PHOTOGRAPH NUMBER ONE WITH AN OBJECT NOT
RELATED TO THE ACCIDENT, AND DOCUMENT THIS OBJECT IN THE PHOTO LOG AS THE START OF A FRESH ROLL OF FILM.
SUBJECT IMPORTANCE TO THE SCENE LENS

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Page 1 of 7

PROJECT / SITE NAME: DATE:

CITY: STATE: TIME OF OCCURRENCE:

REPORT PREPARED BY: SITE EMERGENCY

DESCRIBE HOW INDICENT OCCURRED, ACTIVITY, AUTHORITY, JOB METHOD, ETC.

INJURED: SOCIAL SECURITY NO.

ADDRESS: CITY: STATE: ZIP:

NATURE OF INJURY / ILLNESS:

B ODY PART: SOURCE OF INJURY:

ACTIVITY AT TIME OF ACCIDENT

NAME / ADDRESS OF DOCTOR

NAME / ADDRESS OF HOSPITAL

MODEL / SERIAL NUMBER:

INADEQUATE PROGRAM INADEQUATE PROGRAM STANDARDS INADEQUATE COMPLIANCE WITH STANDARDS

POTENTIAL LOSS IF NOT CORRECTED:

LOSS SEVERITY POTENTIAL: PROBABILITY OF RECURRENCE:

CAUGHT IN CAUGHT BETWEEN STRUCK BY FALL SAME LEVEL

ACTION PLAN: WHAT HAS OR SHOULD BE DONE TO PREVENT SIMILAR LOSS?

ASSIGNED TO: COMPLETED BY:

INFLUENCING FACTORS: (C=CONTRIBUTED; N=NOT A FACTOR; P=PRESENT B UT NOT SIGNIFICANT)

SUBJECT IMPORTANCE TO THE SCENE LENS

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