Sample

Severe Accident Investigation Form

This form should be used to gather information when conducting the investigation of a severe accident.

Question Yes No N/A

Section 1—Task

Was a safe work procedure used?

Had conditions changed to make the normal procedure unsafe?

Were the appropriate tools and materials available?

Were the appropriate tools and materials used?

Was the equipment involved designed for the task?

Should another type of equipment be used for the task performed?

Were safety devices working properly?

Was “lock out” used when necessary?

Section 2—Equipment and Material

Was there an equipment failure? If yes then explain below:

Was the machinery poorly designed?

Is this machine equipped with guards?

Are the guards functioning properly?

Has the machine been maintained?

Were hazardous substances involved?

Were they clearly identified?

Was a less hazardous alternative substance possible and available? If yes then explain.

Was the raw material substandard in some way?

Should personal protective equipment (PPE) have been used?

Was the PPE used?

Section 3—Environment

What were the weather conditions?

Was poor housekeeping a problem?

Was it too hot or too cold?

Was noise a problem?

Was there adequate light?

Were toxic or hazardous gases, dusts, or fumes present?

Section 4—Personnel

Were workers experienced in the work being done?

Had they been adequately trained?

Documented?

Can they physically do the work?

Clarification of Section 4

Section 5—Management

Were safety rules communicated to and understood by all employees?

Were written procedures available?

Were they being enforced?

Was there adequate supervision?

Had hazards been previously identified?

Had procedures been developed to overcome them?

Were unsafe conditions corrected?

Was regular maintenance of equipment carried out?

Were regular safety inspections carried out?

Where was the supervisor at the time of the accident?

What was the supervisor doing at the time of the accident?

What did you see?

Hear?

In your opinion, what caused the accident?

How might similar accidents be prevented in the future?