Supervisor's Accident Investigation Form

Supervisor’s Accident Investigation Form
Name of Injured Person: Fred Flinstone

Date of Birth : 09-30-1960 Telephone Number : 714-808-4500
Address 123 Yabba Dabba Street, Bedrock, CA 92801
City __________ Bedrock ___________________ State__ CA _____ Zip: 92801
(Circle one) Male Female
What part of the body was injured? Describe in detail: right shoulder was bruised, and right arm was
broken.
What was the nature of the injury? Describe in detail: The employee was working when there was a
wind that provoked the incident
Describe fully how the accident happened? What was employee doing prior to the event? What
equipment, tools being using?
He was removing a large rock from the quarry floor with the brotno crane and there was a big gust of
wind. The wind caused the bolder to sway and the bolder slammed into the him and the bronto crane. The
bolder hit his right shoulder and arm.
Names of all witnesses: Barney Rubble
Date of Event ____9/30/1995___Time of Event _______10:25am __________________________
Exact location of event: In the rock quarry station number 3.
What caused the event? Based on the description The wind caused the bolder to sway and the bolder
slammed into the him
Were safety regulations in place and used? If not, what was wrong? There is no information
Employee went to doctor/hospital? Doctor’s Name: Yes- Dr. Sam Sawbones
Hospital Name: Bedrock Hospital, 456 Hospital Dr. Bedrock, CA 92801
Recommended preventive action to take in the future to prevent reoccurrence.
It is recommended to give the proper training to employees making an emphasis in the weather
conditions.
Joyce Espinoza 9/30/1960

______________________ ___________
Supervisor Signature Date
Incident Investigation Report
Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.
(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)
This is a report of a:  Death  Lost Time  Dr. Visit Only  First Aid Only  Near Miss
Date of incident: 9/30/1995 This report is made by:  Employee  Supervisor  Team  Other_________
Step 1: Injured employee (complete this part for each injured employee)
Name: Fred Flinstone Sex:  Male  Female Age: 35

Department: Bronto Crane Operator Job title at time of incident: Bronto Crane Operator
Part of body affected: (shade all that apply) Nature of injury: (most This employee works:
serious one) Regular full time
Abrasion, scrapes Regular part time
Amputation Seasonal
Broken bone Temporary
Bruise Months with this
Burn (heat) employer 120
Burn (chemical) months
Concussion (to the head) Months doing this
Crushing Injury job:
Cut, laceration, puncture
Hernia
Illness
Sprain, strain
Damage to a body system:
Other ___________
Step 2: Describe the incident
Exact location of the incident: In the rock quarry station number 3. Exact time: 10:25am
What part of employee’s workday?  Entering or leaving work  Doing normal work activities
 During meal period  During break  Working overtime  Other___________________
Names of witnesses (if any):
Barney Rubble
2
Number of Written witness statements: none Photographs: none Maps / drawings:
attachments:
What personal protective equipment was being used (if any)? There is no description of it
Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials
and other important details.
He was removing a large rock from the quarry floor with the brotno crane and there was a big gust of wind. The wind
caused the bolder to sway and the bolder slammed into the him and the bronto crane. The bolder hit his right shoulder and
arm.
Description continued on attached sheets: 
Step 3: Why did the incident happen?
Unsafe workplace conditions: (Check all that apply) Unsafe acts by people: (Check all that apply)
Inadequate guard Operating without permission
Unguarded hazard Operating at unsafe speed
Safety device is defective Servicing equipment that has power to it
Tool or equipment defective Making a safety device inoperative
Workstation layout is hazardous Using defective equipment
Unsafe lighting Using equipment in an unapproved way
Unsafe ventilation Unsafe lifting
Lack of needed personal protective equipment Taking an unsafe position or posture
Lack of appropriate equipment / tools Distraction, teasing, horseplay
Unsafe clothing Failure to wear personal protective equipment
No training or insufficient training Failure to use the available equipment / tools
Other: _____________________________ Other: due to weather conditions which caused the
sway and the bolder slammed
__________________________________
Why did the unsafe conditions exist?
Due to weather conditions
Why did the unsafe acts occur?

It occurred because of the weather that was unpredictable.
Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may
have encouraged the unsafe conditions or acts?  Yes  No
If yes, describe:
Were the unsafe acts or conditions reported prior to the incident?  Yes  No
3
Have there been similar incidents or near misses prior to this one?  Yes  No
Step 4: How can future incidents be prevented?

What changes do you suggest to prevent this incident/near miss from happening again?
Stop this activity  Guard the hazard  Train the employee(s)  Train the supervisor(s)
Redesign task steps  Redesign work station  Write a new policy/rule  Enforce existing policy
Routinely inspect for the hazard  Personal Protective Equipment  Other: ____________________
What should be (or has been) done to carry out the suggestion(s) checked above?
Since this incident had never happened, the HR department will carry out some trainings to prevent these incidents. This
is a precedent of what and how to do when there is a bad weather condition. To do this, the following dates are going to
be for training all the personnel from the company.
March 20: what to do to prevent accident in bad weather conditions
March 25: how to use the equipment when weather conditions occur
These trainings will help us to know what to do and how to respond when there is a bad weather condition.
Description continued on attached sheets: 
Step 5: Who completed and reviewed this form? (Please Print)

Written by: Joyce Espinoza Title: Report of Employee’s Injury
Department: HR Date: 2/13/2022

Names of investigation team members:
Reviewed by: Title:
Date:

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Supervisor’s Accident Investigation Form

Name of Injured Person: Fred Flinstone

Joyce Espinoza 9/30/1960

Name: Fred Flinstone Sex:  Male  Female Age: 35

Step 2: Describe the incident

Description continued on attached sheets: 

Step 3: Why did the incident happen?

Why did the unsafe acts occur?

Step 4: How can future incidents be prevented?

Description continued on attached sheets: 

Step 5: Who completed and reviewed this form? (Please Print)

Department: HR Date: 2/13/2022

Reviewed by: Title:

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