ACCIDENT INVESTIGATION FORM
Ref: HSA001 - Accident/Incident Reporting and Investigation
Part A – The Injured Person
Accident reference number 123456789
(H&S Team only)
Name: Steven Buckley
Address: 1 Fictional Street, Liverpool, L40 7BS
Part B - Investigating Officer
Name: Stephen OBrien
Address: 25 Ince Avenue, Liverpool, L4 7US
E-mail:
Post Code: L4 7US Telephone no: 07780793231
Part C - Information Gathering
1. Where did the accident happen?
Carpentry Workshop & Main Workshop
2. Who was injured or suffered ill-health?
Injured Person Steven Buckley
3. What injuries or ill-health effects were caused?
Multiple fractures including head injuries requiring emergency treatment, temporary loss of mobility involving
long term recuperation in hospital.
4. How did the accident/incident happen? (Note working environment issues, layout, equipment and/or
substances involved – did these influence the accident?)
Steven Buckley fell from the mezzanine floor above the main workshop area due to the failure of the
protective guard rail. Workshop training areas include various activities such as bricklaying, plastering,
painting and decorating and carpentry. These areas also mimic construction site working activities such as
working at height, hand tools and electrical equipment. Upon closer inspection several bolts had become
loose which caused the guard rail to fail.
5. What activities/tasks were being carried out at the time of the accident?
Steven Buckley was supervising the work of trainee carpenters.
Ref: HSA001 - Accident/Incident Reporting and Investigation
Part A – The Injured Person
Accident reference number 123456789
(H&S Team only)
Name: Steven Buckley
Address: 1 Fictional Street, Liverpool, L40 7BS
Part B - Investigating Officer
Name: Stephen OBrien
Address: 25 Ince Avenue, Liverpool, L4 7US
E-mail:
Post Code: L4 7US Telephone no: 07780793231
Part C - Information Gathering
1. Where did the accident happen?
Carpentry Workshop & Main Workshop
2. Who was injured or suffered ill-health?
Injured Person Steven Buckley
3. What injuries or ill-health effects were caused?
Multiple fractures including head injuries requiring emergency treatment, temporary loss of mobility involving
long term recuperation in hospital.
4. How did the accident/incident happen? (Note working environment issues, layout, equipment and/or
substances involved – did these influence the accident?)
Steven Buckley fell from the mezzanine floor above the main workshop area due to the failure of the
protective guard rail. Workshop training areas include various activities such as bricklaying, plastering,
painting and decorating and carpentry. These areas also mimic construction site working activities such as
working at height, hand tools and electrical equipment. Upon closer inspection several bolts had become
loose which caused the guard rail to fail.
5. What activities/tasks were being carried out at the time of the accident?
Steven Buckley was supervising the work of trainee carpenters.
