FOR-SEG-7.

0-13

ACCIDENT OR INCIDENT INVESTIGATION

DATOS DEL ACCIDENTE N°: Date Time

Project Place/ Building

Worker Name Company Position

Social Security Number Task Domain Total Partial New

Task

(Describe clearly and exactly how did the accident happen. Annex photos or schemes if he believes it
ACCIDENT DESCRIPTION
adapted having tact in the images)

ACCIDENT CLASIFICATION

Probability: High: It can happen frequently, at least monthly (it happens every month) / Medium: It can happen frequently at least annually (it happens every year) / Low: It
can happen very occasionally, not reaching an annual frequency ( it happens from year to year)

Severity: High: They produce permanent incapacitating injuries or the loss of life /Medium: They produce injuries with treatments over 7 days for full recovery of work capacity
/Low: They produce injuries with treatments less than 7 days for full recovery of the work capacity

Probability High Medium Low Severity High Medium Low

(Reduces the possibility of recurrence while the final solution is being implemented)
IMMEDIATE PROVISIONAL ACTIONS

Actions Responsible Date

Injuries Suffered

Nature and location of the injury

Treatment

Consequence

Observations

ACCIDENT ANALYSIS (Classification)

Name and signature of the
Accident without loss of days Accident with loss of days paramedic who attended

JHVG Fecha de Revisión Febrero 2021

 FOR-SEG-7.0-13

ACCIDENT OR INCIDENT INVESTIGATION

DETAILED INVESTIGATION REPORT (Description of all the observations and evidence found in the place of the accident)

OTHER ATTACHED INFOMACION PHOTO WITNESSES' REPORTS DIAGRAMS OTHERS

ACCIDENT ANALYSIS (Determination of Causes) Use the Fish Spine Technique for the analysis of the extension data
PROBABLES CAUSES (Identify which causes are in accordance with the description of the accident and the extension data)
Person Tools Materials
ACCIDENT
/INCIDENT
Environment Method Equipments

ROOTS CAUSE (From each of the probable causes ask: Why? Until determining the Root Cause)
If the person is the probable cause, ask if: 1) Did you know what was expected? Does Clear expectations? 2) Was he well trained? Do you have the
knowledge and skills? 3) Did you have the opportunity? Do you have time, tools, material, machines, explicit standards and / or resources to act safely? 4)
Having verified that none of the previous options are root cause of the questionable behavior, there is evidence of the lack of commitment of the person.

CONTROL ACTIONS Remember: 1) Check if the actions coincide with the root causes. 2) If there is a similar situation in the Work.
Remember that recommendations should be practical, not expensive, sustainable over time and focus on the factors that both the employee and
supervisor have control over.

RECOMMENDED ACTIONS Responsible Date

Investigation Team: Reviewed by:

Name and Last Name position Date Name and Last Name Position Date

FIRMAS

JHVG Fecha de Revisión Febrero 2021