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P. 62
SF001
Accident Investigation Form Issue 1
03/09/2012
Overlaid By
Anti-slip treated surface Frost / Ice / Snow Grease / Oil Gritted / Sanded Polished
Other State
Other Conditions Wet Dry Not applicable
Even Uneven Not applicable
Level Sloped Steps Not applicable
Nature
Acting as COSS Driving rail vehicle Walking on track with Lookout
Acting as Eng. Supervisor Driving road vehicle Walking on track without Lookout
Acting as Hand signalman Inspecting track with Lookout Working alone
Acting as Lookout Inspecting track without Lookout Working on track with Lookout
Crossing line without Lookout Other non-trackside activity Working on track without Lookout
Crossing line with Lookout Other trackside activity
8. Competency
Formal Competency
Competency Required for Task? Yes No If yes write certification expiry date below
Lookout / / COSS / / PTS / /
Other State what:
9. PPE
Personal Protective Equipment
PPE Required? No Yes State which? –
PPE Provided? No Yes Was PPE Adequate? No Yes
Instructed in its use? No Yes Used Correctly? No Yes
10. Equipment etc Involved
Was a vehicle involved? Yes No What was it? (type)
Make / Model Registration / ID No
Speed vehicle was travelling? Owner
Was a machine or tool involved? Yes No What was it? (type)
Was it appropriate for task? Yes No Identity number
Was it appropriately used? Yes No Owner
Was plant or machinery involved? Yes No What was it? (type)
Was a hazardous substance involved? Yes No What was it?
11. Witnesses & Photos
Were any photos taken? Yes No Are photos attached? Yes No
Were there any witnesses? Yes No Are Witness statements attached? Yes No
Please send all completed forms back to PHoSS Page 3 of 6
Page 1 of 6
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