Electrical Accident Investigation
Date of Accident ______
Jobsite______
Accident Location ______
Electrical Contractor ______
General Contractor ______
Construction Management Co. ______
Owner of Site / Project ______
Trade & Contractor Employed by or Subcontractor to ______
Specifics on Electrical Fault
Accident Involves:
Temporary Power ______Permanent Power ______Utility Co.Side ______
Equipment Involved ______
Manufacturer ______
Line Side ______Load Side ______
Voltage Involved ______
Circuit Ampere Rating ______
Single Phase ______Three Phase ______
Phase to Ground ______Phase to Phase ______
Approximate % of Equipment Damaged ______
Estimated Size of Flashover ______
Description of the Incident
Incident Type: Accident ______Near Miss Involving Electricity ______
Number of Injuries ______Number of Fatalities______
Describe the events and conditions leading to the incident: ______
How did the incident occur and what were the results? ______
Injured Employees (Name & Social Security #)
- ______
- ______
- ______
Other Employees Involved in the Incident
- ______
- ______
- ______
Specifics: Employee Injuries
(Recopy this page for each employee)
Name ______
Social Security # ______
What was the employee doing prior to injury? ______
Describe how this specific injury occurred: ______
Using the Rule of “9”s, Circle Portions Effected (See human diagram)
Classify sections of skin severity
A= Superficial (first degree)
B= Partial Thickness (second degree)
C= Full thickness (third degree)
Did the occurrence result in a fatality (death)? ______
Was there a loss of consciousness? ______
Did “current” flow through body? ______
Indicators are no let go, breathing and heart problems.
(Breathing problems may occur from inhalation during flashover)
Description of Body Parts or Section Injured: ______
Other considerations:
- Power Circuit Route / Source to Location______
- Size Wire / Copper or Aluminum Feeder ______
- Equipment Ratings (NFP 70 Classifications) ______
- What Is Energized and What Is Not ______
- The Work Area In Proximity to Live Energized Circuits ______
- Tools Involved ______
- Flashover -Tell Tale Carbon Signs Blackened Areas (take multiple photos)
- EMS Service Utilized ______
- Hospital Admission / Treating ______
Recommendations for Prevention of Re-Occurrence: ______
Comments: ______
Investigated by: ______
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