incident/ accident recording and investigation ...incident/ accident recording and investigation...
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INCIDENT/ ACCIDENT RECORDING
AND INVESTIGATION REGISTER
(Occupational Health and Safety Act, 1993)
Name of Employer
__________________________________________________________
__________________________________________________________
Complements from Labour Guide 2
Incident/ Accident Recording and Investigation Register
Name of investigator(s):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
___________________________________________________________________________________
Date of investigation:
___________________________________________________________________________________
Designation of Investigator(s):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________
Inju
red
pe
rso
ns d
eta
ils,
an
d i
ncid
en
t d
eta
ils
Name of
injured
Employee Yes No
Date of incident /
accident
201…/…/… Time of incident /
accident
Place of incident/
accident
Injured persons
ID no
Employee address
Date,
incident was
reported
201.../…/…
Time,
incident was
reported
Reported to?
Complements from Labour Guide 3
Typ
e o
f Lo
ss
Property damage Y N Disabling lost time Y N
Fire Y N Medical Y N
Explosion Y N First aid Y N
Spillage Y N Motor vehicle accident Y N
Public accident Y N Occupational disease Y N
Theft Y N Fatality* Y N
Assault Y N Y N
Off the job Y N Y N
Pe
rio
d o
f
dis
ab
lem
en
t
0-13 days 2-4 weeks
>4-16 weeks
>16-52 weeks
>52 weeks or permanent disablement
Killed*
*Was the incident reported to the police? Y N SAPS office and reference:
Was the incident reported to the Compensation Commissioner?
Y N Was the incident reported to the Provincial Director?
Y N
Was hazardous chemical substance(s) involved?* Y N
*Machine/process involved/type of work performed/exposure:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
__________________________________________________________________________________
Complements from Labour Guide 4
D
escri
pti
on
of
In
cid
en
t
Natu
re o
f in
jury
/ dis
ease
Sprains
Type o
f in
cident/
acc
ident
/ dis
ease
Struck by
Part
of body a
ffect
ed
Head
Strains Struck against Hand
Bruises Fall same level Fingers
Wounds Fall diff. Level Eye
Fractures Inhalation Arm / elbow
Unconscious Absorption Neck
Burns Ionising
radiation
Leg
Poisoning Caught in Trunk
Amputation Caught between Foot
Electric Shock Foreign body (eye)
Toes
Asphyxiation Vehicle collision Back
Multiple Electrical
contact
Internal
Occupational
Disease
Temperature
extreme
Multiple
Type of Disease
Complements from Labour Guide 5
List of witnesses
Initials Surname Department Contact details Direct or indirect
witness
1
2
3
4
5
6
7
8
9
10
Complements from Labour Guide 6
Supervisor(s) detail
Initials Surname Department Contact details Direct or indirect supervisor
1
2
3
4
Complements from Labour Guide 7
COID: “Person Event Details” Related Info
Agent (What injured the person/ object?): Example - “Stairs”
_______________________________________________________________________________
Activity (How was the worker injured?): Example – “Fell down”
_______________________________________________________________________________
Actions (Wat was he/ she doing when he got injured?): Example – “Walking”
________________________________________________________________________
What was the employee doing at the Time of the Event?
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
_______________________________________________________________________________
Did this Accident lead to the Death of the Person?
Fatality? O
Injury? O
Total #Months in Industry
Did Accident occur at Normal Workplace?
Was this a Road Accident?
Was this an Assault?
Did the employees spectacles break during the accident?
Were the employee’s dentures damaged during the accident?
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Complements from Labour Guide 8
Travel on Business O
Travel to Training/Test/Seminar O
Travel to/from Work O
Callout O
StandBy O
Public Road O
Private Road O
Employee Vehicle Make
Employee Vehicle Reg No.
Other Party Vehicle Make
Other Party Vehicle Reg
No
Police Reference No
Police Station Name
Complements from Labour Guide 9
Provide brief description of the incident/accident/occupational disease as seen by the
investigator
Complements from Labour Guide 10
Direct/ Immediate Causes
Complements from Labour Guide 11
Un
sa
fe A
cts
Id t
he indiv
idual or
team
act
ions
that
contr
ibute
d t
o t
he inci
dent Improper lifting Working without
authority
Adjusting or working on
moving machinery
Not using PPE Failure to secure
machinery/material
Taking up unsafe
positions
Improper use of PPE Using defective equipment
Drinking or drugs
Improper use of
equipment
Arranging or placing
object unsafely
Safety regulations,
procedure or rule ignored
Driving too fast Fooling, teasing abusing
workmates
Working at unsafe
speed
Using equipment in an
unsafe manner
Un
sa
fe C
on
dit
ion
s
Id t
he c
onditio
ns
that
contr
ibute
d t
o t
he
inci
dent
Inadequate or broken
equipment
Overcrowding in
workplace
Inclement weather
Gas leak No personal protective
equipment
Operate at unsafe
speed
Poor road conditions Unsafe lighting Poorly marked walkways
Poor housekeeping Storage of hazardous
substance
Poor ventilation
Unsafe construction
Inadequate warning
system
Unsafe design
Inadequate guarding Fire and explosion hazard
Unsafe clothing
Defective working
conditions
Poor housekeeping
Thermal conditions
Poor layout Excessive noise
Poor floor condition Radiation exposure
Indirect causes
(Set the stage for the incident, they are the reasons or causes for unsafe acts or conditions)
Hu
ma
n F
acto
rs
Id p
oss
ible
hum
an f
act
ors
that
contr
ibute
d t
o t
he
direct
cours
e
Lack of knowledge Drug or alcohol abuse
Lack of skill Stress
Tried to avoid discomfort
Physical or emotional problems
Failure to follow
instruction
Preceding medical
condition
Willful deviation Was ill, fatigued or incapacitated
Failure to use PPE Dermatitis
Failure to secure Allergies
Failure to plan Excessive overtime
Horseplay Abuse or misuse
Impairment (fatigue, substance abuse)
Lack of motivation
Complements from Labour Guide 12
Wo
rkp
lace
(Jo
b)
Fa
cto
rs
Id t
he w
ork
pla
ce f
act
ors
that
contr
ibute
d t
o t
he
direct
cours
e
Inadequate work
standards/ procedures
Improper
substitution
Excessive vibration
Inadequate purchase
standard
Tampering Inadequate supervision
Inadequate security standard
Mechanical failure Unnecessary material handling
Inadequate fire
equipment & training
Delays Inadequate transport
facilities
Abuse or misuse Inadequate planned maintenance
Unscheduled overtime
Inadequate tools & equipment
Inadequate planned inspections
Wear and tear
Inadequate engineering Inadequate emergency
planning
Manufacturing errors
Inadequate ergonomic design
Congestion, lack of storage space
Excessive vibration
Excessive heat / cold control
Unauthorised removal
Inadequate personnel
selection
Excessive noise
Which process could prevent a recurrence?
Po
ssib
le r
oo
t ca
use
s
Root
cause
s underlie
all
oth
er
cause
s
Buildings & Floors Good lighting Ventilation
Pollution: Air, ground,
water
Aisle and storage area
demarcation
Good housekeeping
Colour coding Machine guarding General electrical installation
Notices and signs Lifting gear records PPE
Ladders, stairways,
walkways, scaffolds
Earth Leakage Committees and
communication
Motorised equipment Hearing Conservation Pre-employment
medicals
Ergonomics No outdated risk assessments
Written Safe Operating procedures
Accident recording and
investigation
Lack of knowledge Safety Policy
Safety awareness Lack of skill Hygiene
No outdated standards Statutory appointments Waste removal system
Lock-out system and usage
Safety Training Labelling switches and circuits
Compressed gas
cylinders / pressure vessels
Safety Specifications Fire prevention and
control
Hazardous substances
control
Hand tools Selection and
placement
Emergency preparedness
First aid facilities
Planned Job Observation
Off the job safety
Complements from Labour Guide 13
Co
rre
cti
ve
Acti
on
Revise selection and placement
Revise inspection program
Correct order, housekeeping
Revise job training Revise Planned Job Observations
Improve design
Improve standards
compliance
Retrain, re-instruct,
workers
Retrain, re-instruct
others
Improve first aid training & equipment
Perform proper on the job analysis
Revise SOP’s
Install guard or safety
device
Job rules, revise Revise risk
assessments
Revise PPE program Post warnings
Repair defects Issue loss
announcement
Suspected cause(s) of the incident (Direct, Indirect, Root)
Complements from Labour Guide 14
Complements from Labour Guide 15
Recommended steps to prevent a recurrence (Investigators)
Complements from Labour Guide 16
Action taken by employer to prevent the recurrence of a similar incident (Management)
To be completed by:
Date:
Complements from Labour Guide 17
Remarks by the safety committee, chairperson of the safety committee
Complements from Labour Guide 18
Follow - up
By:
Date of follow-up:
Signature of
accident /
Incident
Investigator(s)
Date:
Signature of
employer
Date:
Signature of
Chairperson of
the safety
committee
Date: