Accident/ Incident Investigation

Name and Age of Employee

Employees Job Title
Job at time of Accident/ Incident
(a) Full‐time (b) Part‐time (c) Temporary (d) Seasonal
Type of Employment
(e) Other:
Length of time with Company
Length in current position with Company
Description and severity of Accident/
Incident
Date and time of Accident/ Incident
Location of Accident/ Incident
Name of Interviewee: -

S.
Information Required Reply Remarks
No.
Who first responded after accident/ incident
1.
occurred?
2. Who witnessed accident/ incident?
How long had victim been working on the day
3.
of the accident/ incident before he was injured?
4. Who has done the same job before?
What shift did the accident/ incident occur on?
5.
When did shift start?
6. Was the individual working overtime?
7. Who trained the victim on the job?
Who installed equipment (if accident/ incident
8.
involved a piece of equipment)?
9. Who inspected the equipment? When the
equipment was last inspected and or
 maintained?
Who told the victim to do the work he or she
10.
was involved in at time of accident/ incident?
11. Where did accident/ incident occur?
Where was the victim at the time of the
12.
accident/ incident? Where were the witnesses?
13. Where was the supervisor?
14. What happened?
What was the victim doing at the time of the
15.
accident/ incident?
Was the victim competent for doing that
16. particular job? Documents clarification, if
needed.
What was the victim doing immediately prior
17. to the accident/ incident? If this was not the
victim’s regular job, what was his regular job?
Was the victim working in crowded
18.
conditions? i.e., too close to another worker?
Was there anything different or abnormal on
19. the day of the accident/ incident, with respect
to working conditions or the work being done?
 Was the job understaffed or under crewed on
the day of the accident/ incident or at the time
20. of the accident/ incident? i.e. if three people are
needed to do the job safely, were all three
people working and present?
Was there more work to do than normal on the
day of the accident/ incident (thus putting
21.
pressure on the worker(s) to work faster or to
bypass safety devices)?
Were workers asked to work overtime on the
22.
day of the accident/ incident?
Had anyone else ever been injured on the same
23. job, same piece of machinery, etc. (Go back in
time as far as you think reasonable)?
Had there been any near misses on the same
24.
job, same piece of machinery, etc.?
Had concerns about the safety of the job, piece
of machinery, or environmental conditions,
25.
been raised with management previous to the
accident/ incident occurring?
26. What language does (did) the victim speak?
What language does the victim’s supervisor
speak? In what language was the safety
 training and any other training concerning the
job conducted?
Was PPE required for the job on which the
accident/ incident occurred? If PPE was
27.
required, exactly what kind of PPE was
required?
In the course of the investigation, does it
28. appear that the PPE was inappropriate for this
particular job?
Was the victim wearing the
29.
required/appropriate PPE?
Were there any problems with the PPE on the
30. day of the accident/ incident? i.e. was the PPE
defective, ill-fitting, had holes, etc.?
Could the PPE in any way have been a
31. contributing factor to the occurrence of the
accident/ incident / injury?

Recommendations should address:

• Issues related to the specific accident/ incident
• Issues related to similar situations, conditions, equipment
• Management system deficiencies
• Effective Controls and Prevention Actions
• Evaluation of controls and Prevention Actions
• Follow-up