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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
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