Jobsite Incident

Steps

Yes

No

1. Employee notifies supervisor of

incident

2. Is this an Emergency?

Call 911 and Immediately call Dir. Of ED. & LP.

Immediately call Dir. Of ED. & LP.

3. Dir. Of ED. & LP. will provide

instruction on how to manage the injury or damage.

4. Did this incident result to an

injury?

Does the employee need to see a doctor?

Full Accident Report – Once the report is complete DO NOT send to the client. All accident reports must first be signed by the Director of Education and Loss Prevention and the VP of Operations. Email the completed accident report to The Education and Loss Prevention Coordinator.

5. Does the employee need to see

a doctor?

Call Dir. Of ED. & LP. before taking the employee to a clinic. In most cases the executive will meet the employee at the clinic in order to manage the case. The employee can choose which provider they would like to see based on the list provided on the template named Accidents: Doctors list for medical care, Employees may not use their personal doctor for work related injuries

Provide care for the employee based on your level of knowledge and training or have the employee self-care.

6. Begin an accident report titled

Accident: Full Accident Report – Once the report is complete DO NOT send to the client. All accident reports must first be signed by the Director of Education and Loss Prevention and the VP of Operations. Email the completed accident report to The Education and Loss Prevention Coordinator.

As soon as you arrive to the scene:

• unlock your Ipad, phone.

• Open IAuditor App, www.safetyculture.com

• Log into IAuditor with your specific username and password.

• Go to templates folder and search for Full Accident Report.

• Once you find it click on start inspection.

• Follow Instructions given above the boxes to fill in specific data for that box.

• Once filled out click on complete, it will save your report and then you can export it to pdf or word file.

• Your completed form should look like the example below.

Accident Report Sheet

An accident report sheet is used to document job site accident. In the example we will teach

you how to perform a root cause analysis based on your incident/ circumstances.

Incident: John Doe drove his vehicle into a trench on the jobsite. By working through this

accident report sheet, we will be able to find out what led to this accident and what corrective

measures should be taken.

Corrective action plan: This box will have all the steps to ensure that this incident doesn’t

happen again including training, actions, changes to processes, etc.

Casual Factors: This box will have the factors that led to the incident happening but will not

always include root cause.

Select the Accident code: In this box you will have to select all the accident codes that are

related to your incident.

Auto – Their Fault: The incident involved an automobile and is not E light’s, Employee’s fault.

Auto – Our Fault: The incident involved an automobile and is E light’s, Employee’s fault.

Blasting Accident: where someone gets injured due to a blast or an explosion.

First Aid only: where there is no major injury just a small scratch, strained muscle or something

that will only require first aid.

Incident Only No Injury or Illness: There will be an incident though no injury or illness due to

that incident.

Injured or Illness Non-Recordable: where there will be minor injury or illness which will not be

recorded by OSHA.

Liability Property Damage to Property not owned by E Light: Damage to property or equipment

which is not owned by E Light Electric Services, Inc.

Non-Occupational incident not related to work or caused by work: Any injury or illness that is

not related to work, pre-existing medical conditions like asthma.

Osha Recordable injury accident that will be listed as a recordable incident: any injury or illness

which would restrict work and for which the doctor would prescribe medication. For example:

receiving stitches, receive an injection, if they have to go through surgery, if they get any

fracture.

Root Cause: This box should contain only the root cause of the incident which you will get to by

performing root cause analysis.

Root Cause Analysis: you go through the process of asking why the answer to the previous

question happened until you reach a valid conclusion.

Why did John Doe drove into the trench? Because he was not watching where he was going.

From there we question why each previous factor occurred and work our way through and

keep asking why until we reach the root cause of the incident.

Accident: FULL ACCIDENT REPORTAccident: FULL ACCIDENT REPORT Complete

Inspection score

100%

Failed items

0

Created actions

0

HAVE YOU CALLED THE DIRECTOR SAFETY AND LOSS PREVENTIONAND INFORMED HIM OF THE INCIDENT? If no, call immediately at303-550-5292

Yes

Document No.

INCIDENT 000002

Conducted on

4th Feb, 2020 8:00 AM MST

Reported By:

Chaitanya Bhavsar

Report prepared by:

Employee full name

Location. [Use the Find Me Option and allow GPS locating]

357 Inverness Dr S, Englewood, CO 80112, USA

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Audit 100%

Personnel

Click add to enter the information concerning the persons involved in the incident. Enter the main partiesfirst and then add other involved persons such as witnesses.

Involved Person

Involved Person 1

First and Last Name

John Doe

Best contact phone number: (000-000-0000)

000-000-0000

Classification of Person E Light Employee

Involvement Injured Party

Has this person been sent for a post accident drug screen? Yes

Involved Person 2

First and Last Name

Ted Riley

Best contact phone number: (000-000-0000)

000-000-0001

Classification of Person E Light Employee

Involvement Direct Supervisor

Classification of Incident First Aid (First Aid Only Accidentin Any Location)

Date and time of the incident.

4th Feb, 2020 8:00 AM MST

Project Name

Atlantis mall

Enter the exact location on the project where the incident occurred.

on the street of parking lot.

Incident Reported By: (Name of the person the incident was reported to. This is typically a supervisor.)

Ted Riley

Date and time incident was reported by the employee. (Be sure to enter the time and date this was reported and not the default datewhich is the current date and time.)

4th Feb, 2020 8:00 AM MST

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Phase code/Job Cost (This should be the Phase Code for the work that the employee was doing at the time of the accident.)

AM-065

Project Number

180012

Corrective Action Plan: (Enter all items which will be done by the employee and E Light to help ensure this type of incident will nothappen again. Include training, action items, changed processes, etc.)

Red rope around the trench, signs and boards showing trench, there will be one person who would guideeveryone driving around it.

Incident Description: (Enter a concise description of the incident and include only facts)

John Doe was trying to drive out of the construction site, when his car fell into a trench.

Immediate Actions taken: (Describe the immediate actions of the employees, supervisors, first responders, etc.)

John Doe was removed from the vehicle right away by the first responders, they also checked on hisbroken leg and vitals, then took him to Concentra urgent care.

Investigation Findings: (Provide detailed findings of your investigation. DO NOT INCLUDE CAUSAL FACTORS IN THIS SECTION.)

Plumbers had an open trench without barricades, red rope and employees car fell into it.

Causal Factors: (List all the causal factors which apply to this incident. Identify One and ONLY ONE ROOT Cause and list it at the endof this section. NOTE: Your Corrective Action Plan should address each of the items in this section.)

employee was not aware of the trench but should have been paying attention, Plumbers had an opentrench without barricades, red rope and employees car fell into it.

Select the type of Incident+ Resource ( Employee)

+ Equipment or Property

Employee Name: (Name of the injured employee or the primary employee involved in the incident)

John Doe

Select the Accident Code

+ Injured or Illness (INJ/ILL) NONRECORDABLE+ Liability (LIAB) PropertyDamage to Property Owned byothers, Not owned by E Light

Supervisors Name: (Enter the name of the employees direct supervisor)

Ted Riley

Superintendent/Construction Manager: (Enter the name of the Site Superintendent or Construction Manager)

joe trash

Project Manager/Site Manager: (Enter the name of the project manager or site manager)

harry pots

Hospital/Treatment Center: (Enter the Name, Street Address, City, State, Zip and Phone Number. Make sure you enter all of therequired data in the order listed.)

11877 E Arapahoe Rd, Centennial, CO 80112, (303) 792-7368.

Was the employee hospitalized? No

Attending Physician: (Enter the Name, Street Address, City, State, Zip and Phone Number for the attending physician. Make sure youenter all the required data in the order listed.)

Dr. Hackleberry, 11877 E Arapahoe Rd, Centennial, CO 80112, (303) 792-7368.

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Enter the email address of the Attending Physician.

dr.hackleberry@concentra.com

Was the employee treated in an Emergency Room? No

Type ( E Lights Internal Classification)

+ Injured or Illness (INJ/ILL) NONRECORDABLE+ Liability (LIAB) PropertyDamage to Property Owned byothers, Not owned by E Light

Is this accident classified an accident or an illness based on the OSHAdefinition.

Injury

Which OSHA district would have jurisdiction of this incident if it were to be investigated by OSHA: ( Enter the Federal OSHA DistrictNumber, or Cal OSHA regional office, or other State Regional Office)

765_OSHA, 123-321-3221Region 8

What Time did the Employee Start Work on the day of the incident?

7:00 am

Object/Substance Cause: (Was there a specific object or substance that caused the accident? ie A hazardous substance.)

No

Root Cause: (Enter One Root Cause for this Incident. This should match the Root Cause listed in the Causal Factors Section)

Management failed to instruct employee about proper rest.

Injury Description: (Enter a description of the injury. ie: Laceration, muscle strain, etc.)

broken leg and strain in neck.

Was First Aid Administered? Yes

What activity was the employee doing when injured? : (List the task that was identified on the employees JHA or Pretask Card)

Driving his car.

Hazardous Material Involved: (Enter the name of the hazardous material involved and the SDS Number. If no hazardous materialinvolved, then enter NONE. )

None.

Select the Body Part Affected. (This is used only if the there is aninjury or illness. If not applicable, select NONE INJURED)

+ Neck

+ Leg

Left

Restricted/ Lost TIme: (If this accident will lead to restricted duty orlost time, select whichever is applicable, If this accident will not beeither Restricted or Lost Time, then select NA)

Restricted Duty

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Insert pictures. Please be thorough with pictures and ensure that pictures are taken of the area, the damage, the persons involved,and any other item which may help those that were not on scene understand the incident.

— Photos

Add a drawing of the location or other items which may help those that were not on scene understand the incident.

Photo 1 Photo 2 Photo 3 Photo 4 Photo 5

Photo 6 Photo 7 Photo 8

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Root Cause Analysis: Note, the Purpose of this section is to keep asking whysomething happened until you determine the one true root cause.

Why did the accident happen?

Employee was not watching where they were going.

Why did the answer to the first question happen?

they were distracted and tired.

Why did the answer to the second question happen?

Not getting enough sleep.

Why did the answer to the third question happen?

Not taking enough responsibility to take care of themselves

Why did the answer to the fourth question happen?

No one spoke to them about importance of proper rest for proper awareness.

What is the root cause of this accident. One sentence answer.

Management failed to instruct employee about proper rest.

What actions are going to be taken to address the root cause of this accident?

Meeting with steering committee regarding job site safety, S.T.O.P Observation to know job site hazards.

Name and Signature of reporting party

Ted Riley

4th Feb, 2020 10:02 AM MST

Title of Reporting Party

Senior Supervisor

This report has been reviewed by the Department Director

Yes

This report has been reviewed by the Director of Education and Loss Prevention

Yes

This report has been reviewed by the VP of Operations.

Yes

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Media summary 8 Photos

Photo 1

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Photo 5

Photo 2

Photo 4

Photo 6

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Photo 7

Photo 8

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