Department Document Name Issue Date: November 2022

HSE Incident Review Date: November 2022

Investigation Form

ACCIDENT INVESTIGATION FORM

INCIDENT DATA AND CLASSIFICATION
SAFETY HEALTH ENVIRONMENT Fire
Fatal Level 5 Catastrophic Repeat Incident
LTI Level 4 Major Nearhit
First Aid Level 3 Moderate Substandard Act
Damage Level 2 Minor Substandard
Condition
Level 1 Nearhit/Major
Nearhit/Minor
Incident Date: Time:
Location: Contractor
:
Activity:
Risk rating of recurrence(tick appropriate box)
FRCG 1- Light vehicles Likelihood/ Insignificant Minor Moderate Major Catastrophic
consequence
FRCG 2-Mobile Equipment Almost certain L M H H H
FRCG 3-Equipment Safeguarding Likely L M M H H
FRCG 4-Isolation Possible L L M M H
FRCG 5-Working at Heights Unlikely L L L M M
FRCG 6-Lifting Operations Rare L L L L L
INCIDENT DESCRIPTION (Include Picture where Possible)

FINDINGS
 Department Document Name Issue Date: November 2022
HSE Incident Review Date: November 2022
Investigation Form

ACTIONS By Who By When

SIGNIFICANT LEARNINGS

Date Investigation Concluded: Lead Investigator: