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 #)

  1. ______
  2. ______
  3. ______

Other Employees Involved in the Incident

  1. ______
  2. ______
  3. ______

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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