Page 62 - On Call folder

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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