Safety Incident Investigation

Transcription

1 INSTRUCTIONS - Safety Incident Investigation Please forward completed investigation reports to the Airside Technical Team (AirsideInvestigations@gatwickairport.com) Include witness statements, training records and other supplementary documentation relevant to the incident and investigation. A Major offence will require the immediate attention of the individuals Line Manager. In all cases, this is to enable a full and robust investigation. Root causes, behavioural factors will be identified and established within the investigation. Remedial measures/actions and sanctions including; retraining, process changes, risk assessments, suspension and disciplinary action to be implemented where appropriate after investigation. Regular review of investigation(s) and outcomes will be completed by the Airside Standards Improvement Lead and Community Stakeholders/3 rd Party Safety Managers, this could potentially result in re-categorisation of Major or removal of Minor offences if individuals involved are willing to share their learnings to help educate others, this is fundamentally important to encourage the development of an environment in which occurrences are reported Incident Contact Details Company: Insert the full company name Minor / Major Code: Investigation Type: Select Category Incident Risk Level:

2 Employee Details Name ID Pass # Job Title Start Date Investigator Details Name Job Title ID Pass # Phone # Incident Details 2.1 Location of incident: Give details of the actual location Pier: Stand: Other: Exact location within this area: 2.2 Damage to property: Give any details to damage to infrastructure, place photos of damage here. 2.3 Environmental conditions: As a guide use the below points of reference Driving Surface Condition: Good Fair Poor Contaminated Detail/other: Weather: Dry Windy Rain Snow Sleet Frost Lighting: Dawn Daylight Dusk Night time Internal Artificial Time of Day:

3 2.4 Employee details: Contract full or part time: Shift start time: Shift end time: Previous 7 days shifts: Breaks taken prior to incident: Was fatigue a factor: Yes or No Other relevant incidents: 2.5 Injury to employee / others: Give any details to any injuries involved in the incident. 2.6 Attendance at Scene: Airfield Ops: Y/N Who: Company Management: Y/N Who: Emergency Services: Y/N Which: 2.7 Photographs: when providing photos please show reference of scale. Insert Photos here

4 3.0 - Summary of event/incident 4.0 Statements: This should be formal interview notes taken under witness of the employee. (Can be attached on a separate sheet) 5.0 Training Records & Risk Assessments Original Assessment date in Task: Date of initial training: Re- Validation of any training under taken: All other Relevant Information: Risk Assessment for the task being completed to be attached. 6.0 Equipment Information Was there pieces of Equipment involved: Y/N Equipment Model involved: Fleet Number: Maintenance schedule: Evidence of last maintenance check (attach): Repeat if more than one piece of equipment involved.

5 Photo of Equipment (attach): 7.0 History of similar events Has there been similar incidents with either fleet type, personnel or area of infrastructure. 8.0 Immediate Actions Taken with employee: Taken with equipment: Area Isolated: Y/N Action taken with regards to pass: ID pass suspended / Skills Suspended 9.0 Contributory factors Identify all unsafe acts and/or conditions that have been identified as Contributory Factors. Describe reasons for each category selected in the comments column Skills Comments Training Skill Level Knowledge Comments Experience in specific task Other Attitude / Behaviour Comments Attention to the task Attitude to the job Attitude to the incident Incorrect use of PPE Following safety rules

6 Other Personal Conditions Comments General health Personal issue or restriction Fatigue Motivation Unexpected illness Other (describe details) Management / Procedures Comments Clearly defined roles / responsibilities Inadequate staffing levels PPE not available or inadequate Risk assessments for the task is fit for purpose Standard Operating Procedures / Safe Systems Of Work for the task Climatic condition / weather Other Infrastructure Comments Clearly marked route of travel Visibility enables safe travel Clearly understood Layout Area in good working condition 10.0 Investigation & Findings Describe the events that led up to the incident occurring, including factors that may have contributed to the incident, Ask Why? Consider incident statement and consequences of incident Statement? Why Consequence? Why

7 11.0 Root Cause Having analysed all factors what is the Root Cause to the incident Corrective Action Plan Identify all actions required to prevent this incident occurring in the future ACTION IDENTIFER CORRECTIVE ACTION CONTENT RESPONSIBLE PERSON/ ORGANISATION

8 13.0 Shared Learnings WHAT? TO WHO? 14.0 Conclusion

9 15.0 Review and Closure Forward completed Investigation reports to * Remember to attach any relevant additional information