ACCIDENT INVESTIGATION QUESTIONNAIRE

1.
Q.1

PEOPLE DUTIES
Was the person concerned carrying out a task that was part of his/her
normal duties?
YES/NO
IF NO, STATE:
a) What was abnormal or different ?

Q.2

Was the task within Job Specification / Desscription of the person

concerned ?
YES/NO
IF NO, STATE :
a) In what way was it outside Job Specification / Desscription ?

b) Who should have carried out the task ?

c) Why should that person perform the task ?

Q.3

Was that person involved in an activity associated with work but not
directly related to as task ?
YES/NO
IF YES, STATE :
a) The activity in which person was engaged

PEOPLE SUPERVISION
Q.4

Was the persons immediate supervisor present in the area at the time of
the accident ?
YES/NO
IF NO, STATE :
a) The location of the supervisor prior at the time

b) Any instruction given by the supervisor to leaving the area?

Q.5

Was the accident reported immediately and to whom ?

YES/NO

IF NO, STATE :
a) Why was there a delay ?

b) How long was the delay ?

Q.6

Was the work carried out according to instruction or normal practice ?

YES/NO
IF NO, STATE :
a) In what way the task carried out that was different from normal practice?

Q.7

Could instruction/information be given to prevent a recurrence ? YES/NO

IF YES, STATE :
a) Nature of instruction

PEOPLE TRAINING
Q.8 Was the task/job within the capability of the person concerned ? YES/NO
IF NO, STATE
a) What additional training was required ?
b) What additional experience was required ?

Q.9 Was the person concerned familiar with plant /type of equipment, tools,etc. ?
YES/NO
a) What knowledge/skill was lacking ?

Q.10 Had the person concerned been trained to carry out the task safely ?
YES/NO
IF NO, STATE
a) What additional safety training could be given to prevent a recurrence ?

PEOPLE PROTECTION
Q.11 Was the specified protective clothing being worn ?
IF NO, STATE :
a) Was it reasonable to wear protective clothing ?

YES/NO

Q.12 Was protective clothing/equipment adequate to deal hazard ?

YES/NO

IF NO, STATE :
a) What improvement could be suggested to improve protective clothing ?

b) Was protective clothing/equipment available

?

MICELLANEOUS
Q.13 Were any of the persons sense listed obscured/nullified which could have
Been a contributory factor ?
YES/NO
SIGHT
HEARING
SMELL
TASTE
TOUCH
IF YES, STATE WHICH :

Q.14 a) List the name of people that might assist in this investigation

b) What were you doing at the time of accident ?

2.

PLANT/EQUIPMENT/PREMISES
Describe plant and equipment and/or premises together with sketch, photo, etc,
and attach.
Q.15 Were plant/equipment/premise in normal condition ?

YES/NO

IF NO, STATE :
a) What modifications or alterations has been made ?

Q.16 Were means fo controlling emergency condition e.g.emergency stop sign,

etc. located near to hand ?
YES/NO
IF NO, STATE :
a) Would such control have reduced the consequence or eliminated the accident?

Q.17 Were guards, protective device effective and/or secure ?

YES/NO

IF NO, STATE :
a) In what way was the guarding of the machine/excavation penetration/plant
insecure or ineffective ?

Q.18 Were warning notice displayed, warning persons of hazard or to use

protective equipment, clothing, etc.
YES/NO
IF NO, STATE :
a) Would such notice have helped avoid the accident ? If so state type and
content of notice

Q.19 Were operating control, electrical, gas, tanks, etc.clearly marked ?

YES/NO
IF NO, STATE :
a) Reasons not clearly marked ?

b) What additional marking, etc. could be made ?

Q.20 Was there free, safe access/egress to location ?

YES/NO

IF NO, STATE :
a) Cause of blockage or

Q.21 Was there any failure of service, component, plant or machinery ?

YES/NO
IF YES, STATE :
a) Outline circumstances leading up to failure and consequence

3.

SYSTEMS
Q.22 Are procedure/instruction laid down for the task ?

YES/NO

IF NO, STATE :
a) What procedure couldbe laid down ?

Q.23 Is there any system for monitoring that procedures/instructions are follow
Followed ?

Q.24 Is there an acceptable safe method for carrying out the task ? Yes/NO
IF NO, STATE :
a) what method could beadvised that would eliminate or reduce accident
pontential ?

Q.25 Are procedure laid down for warning personnel of the hazards of the job ?
YES/NO
IF NO, STATE :
a) What recommendations could be made to improve this situation ?

Q.26 Are permits to work/ clearence certificate normally issued for this type
of work ?
YES/NO
IF NO, STATE :
a) What condition were not being followed ?

4.

ENVIRONMENT
Q.29 Did any of the following environmental factor contribute to the accident ?
YES/NO
IF YES, tick and state conditional factor.
e.g.
RAIN
FOG
SUN
HEAT
COLD
HUMIDITY

Sketch the Location of Accident