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[Insert Company Name]
Guidance Form on Investigation Information Gathering
1. Where and when did the adverse event happen?
Location:
Time:
Were Photos Taken: Yes ☐ No ☐
hh / mm
Date:
Date Accident Report Sent to Park City Consulting:
dd / mm / yyyy
dd / mm / yyyy
2. Who was injured/suffered ill health or was otherwise involved with the adverse event?
Full Name(s):
3. How the adverse event happened (Note any equipment involved):

Bullet point description of chain of events in chronological order:
o
What happened and who did what before, during and after the event?
o
Was there any plant and equipment involved? (Use nameplates of equipment if necessary).
o
List Model numbers, machine numbers, model type, year of manufacturer, supplier?
o
Were shop floor processes or layout changes regular or not?
4. What activities were being conducted before, during and at the time of the event?
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Bullet point the activities/description.
5. Was there anything unusual or different about the working conditions?
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Were there new sources of danger unknown to the employee(s)?
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Were they prepared to deal with the new situations?
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Were work conditions or processes significantly different to normal? (Give detail if so).
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Were employees or operatives unaware of any new working methods involved?
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Were workers or supervisors aware of any changes?
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Were workers and/or supervisors sufficiently trained for any changing circumstances?
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Were there any changes in the ground surface or weather conditions where the injury took place?
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E.g., raining, wet surfaces, icy etc
6. Were there adequate safe working procedures in place and were they followed?
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Evidence of SWPs
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Is there any presence of:
o
Culture of “we’ve been doing it for years?”
o
“Nothing’s gone wrong before?”
o
Blame culture?
o
Passing responsibility onto someone else?
o
Anyone stipulating the cause?
7. What injuries or ill health effects, if any, were caused?
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Please list which parts of the body have been injured.
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Nature of injury i.e., bruising, crushing, burn, cut, broken bone etc.
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[Insert Company Name]
8. If there was an injury, how did it occur and what caused it?

What was the mode of the injury? i.e. Was it a harmful object that inflicted the injury?

The way in which the injury was sustained.
9. Was the risk known? If so, why wasn’t it controlled? If it was not known, why not?
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Was the risk known or unknown?
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Was it communicated to staff?
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Was what the source of danger?
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Was it appreciated and understood by all concerned?
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Were risk controls adequately in place?
10. Did the Organisation and arrangement of the work influence the adverse event? If so, how?
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Were standards of supervision, monitoring, SWPs in place?
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Were there lack of skills and knowledge present?
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Were there inappropriate working procedures taking place?
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Lack of planning?
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Were there consequences of any employee’s actions and priorities?
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Were there high production targets in place?
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Were safety measures degraded?
11. Was maintenance and cleaning sufficient? If not, give details why not.
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State of repair/condition of workplace/premises?
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Housekeeping?
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Were maintenance/examinations conducted?
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Noise?
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Uneven floors?
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Ease of movement around workspaces?
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Lighting?
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Poor storage?
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Slips, trips, and falls?
12. Were the people involved competent and suitable for the activities taking place? If so, give
evidence/records of IITS.
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Were there any misunderstandings?
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Lack of respect toward any person(s)?
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Immaturity/inexperience present?
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Poor handling or work equipment/tools?
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Healthy, fit for work in the role given?
13. Did the workplace layout influence the adverse event? If so, how?
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Sharp table edges?
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Fumes?
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Naked lights?
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Poor Organisation of layout?
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Clear walkways/access?
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FLT movement in area?
[Insert Company Name]
14. Did the nature or shape of the materials influence the adverse event? If so, how?
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Weight, quality, or packaging involved.
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Awkward material to handle?
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Slinters, poisonous chemicals?
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Equipment failing during normal process?
15. Did difficulties using the plant and equipment influence the adverse event? If so, how?
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Were any user instructions available?
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Were any user manuals read before use?
16. Was the safety equipment sufficient? What equipment: was it in place, was it in a serviceable state,
and was it used correctly?
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Extra safety equipment at machines?
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Power supply isolation equipment and procedures in place?
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Was PPE used as appropriate?
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LEV in use, building ventilation system in place as required?
17. Did other conditions influence the adverse event?
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Long working hours?
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Distractions?
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Defective supplies?
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Trespassing or sabotage?
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Disagreements, misunderstandings between person(s) involved?
18. What were the immediate, underlying, and root causes?
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Immediate causes (the agent of injury i.e., the blade, substance, dust etc.).
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Underlying causes (unsafe acts and conditions i.e., guard removed, vent switch off etc.)
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Root causes? (Management failure to identify training needs, assess competence, no risk assessment etc.).
19. Any other points? Evidence? Statements taken? Email correspondence?

Evidence of meetings and minutes?
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Disclosed doctor’s notes?
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