CFT
Administrative
Document / / Page: 1 of 5
Revision no 5
Date reviewed
Issued by.KB/PM/DMcC
Document reference CFT 305 a / Approved by Executive
ACCIDENT REPORT FORM

Office use only

Accident number / Accident Date / Date Form Received

THIS FORM SHOULD BE SENT TO HEAD OFFICE WITHIN 7 DAYS OF AN ACCIDENT

SECTION 1: OBJECTIVES AND CONFIDENTIALITY:

Our objectives for Accident and Near Miss reporting are: learning from our mistakes; sharing information; identifying training needs and identifying areas where equipment is likely to fail.

Our policy with confidentiality of these reports is that only the NDO, CFT Incident’s Officer and CFT Office manager will have access to these reports.Please note, that by submitting this form you agree to allow CFT copy this report to its insurance broker/underwriter, if considered appropriate.

SECTION 2: ACCIDENT DETAILS

DATE: / TIME:
LOCATION: / REGION:

LOCATION AND CONDITIONS:

WHERE ACCIDENT OCCURRED: TICK WHERE APPROPRIATE – There can be multiple ticks
Boat / Pool / Shore / Surface
Underwater / Other
SURFACE WATER CONDITIONS: TICK WHERE APPROPRIATE – There can be multiple ticks
< 0.5m Wave Height / 1m Wave Height / 2m Wave Height / > 2m Wave Height
Spring Tides / Neap Tides / Slack Water / Drift Dive
WIND CONDITIONS: TICK WHERE APPROPRIATE – There can be multiple ticks
Light (Force 0 to 2) / Mild (Force 3) / Moderate (Force 4) / Fresh (Force 5)
Strong (Force 6) / Gale (Force 7 to 8) / Offshore / Onshore
DIVE CONDITIONS Underwater: TICK WHERE APPROPRIATE – There can be multiple ticks
Poor Visibility / Good Visibility / Strong Current / Surge (to and fro)

SYNOPSIS OF ACCIDENT AND DETAILS OF DIVE:

Synopsis of Accident: No need to include names and club details
Details of Dive: Fill out this section if Accident happened during a Dive. Names are not required.
Person Involved: Diver Grade / Buddy: Diver Grade
Person Involved: Dive Depth / Buddy: Dive Depth
Person Involved: Dive Time / Buddy: Dive Time
Person Involved: Gas Mix / Buddy: Gas Mix

INJURIES AND ACCIDENTS

SERIOUS INJURIES: TICK WHERE APPROPRIATE – There can be multiple ticks
Fatality / Blackout / Bleeding (Severe) / Broken Bone
Burst Lung / DCS (Bends) / Drowning / Near Drowning
Ear Drum (Burst) / O2 Toxicity Fit / Other
GAS POISONING ACCIDENTS: TICK WHERE APPROPRIATE – There can be multiple ticks
CO Poisoning- Bad Fill / CO2 Poisoning / Nitrogen Narcosis / O2 Toxicity
EQUALISATION ACCIDENTS: TICK WHERE APPROPRIATE – There can be multiple ticks
Ear Squeeze / Mask Squeeze / Sinus Squeeze / Suit Squeeze
TYPE OF BOAT ACCIDENTS: TICK WHERE APPROPRIATE – There can be multiple ticks
Boat Crash / Capsize / Engine Failure / Man Overboard
Winch Handle / Other
OTHER ACCIDENTS: TICK WHERE APPROPRIATE – There can be multiple ticks
Bleeding (Minor) / Bruising / Burn / Eye Problem
Hypothermia / Missing Diver or Divers (in Water) / Missing Diver or Divers (On Surface) / Shock
Sprain / Other

FACTORS INVOVLED AND SECONDARY SYMPTOMS

FACTORS AFFECTING DIVER BEFORE DIVE: TICK WHERE APPROPRIATE – There can be multiple ticks
Alcohol (last 12 hrs) / Fatigue / Feeling Unwell / Headache
Seasickness / Smoking / Other
FACTORS AFFECTING DIVER IN WATER: TICK WHERE APPROPRIATE – There can be multiple ticks
Breathlessness / Buoyancy (Negative) / Buoyancy (Positive) / Cold
Cramp / Current / Depth / Drift Diving
Entanglement / Equipment Failure / Headache / Missed Deco Stop
Missed Safety Stop / Overexertion / Out of Air / Rescue Lift
Separation / Solo Diving / Other
REACTION TO FACTOR EXPERIENCED ON DIVE: TICK WHERE APPROPRIATE
Aborted Dive / Alt. Air Source / Free Ascent(w/o air) / Overexertion
Panic / Rapid Ascent / Other
FACTORS AFFECTING DIVER AFTER DIVE: TICK WHERE APPROPRIATE – There can be multiple ticks
Breathlessness / Cold / Dizziness / Headache
Nausea / Paralysis / Smoking / Tiredness
Other
BOAT ACCIDENT FACTORS: TICK WHERE APPROPRIATE – There can be multiple ticks
Boat Breakdown / Boat Handling Poor / Boat Over Loaded / Engine Failure
Fuel (Dirty) / Fuel (Out of Fuel) / Trailer – Launching / Trailer – Towing
Winching / Winch Handle / Other
OTHER FACTORS: TICK WHERE APPROPRIATE – There can be multiple ticks
Altitude / Dive planned changed / Dive within Tables / Nitrox
Rebreather / Repetitive Dive / Surface Viz Poor / Training Drill
Trimix / Other

SECTION 3: SERVICES CALLED AND ORGANISATION:

SERVICES UTILISED (Tick where appropriate)
Ambulance / Emergency Services Contacted / Chamber: Diver Transferred / Coastguard
Doctor / Garda / Helicopter / Hospital
Other
ORGANISATION (Tick where appropriate)
Cover Boats / Cover diver / Diver Aborted / Divers Recalled
Emergency Plan / Emergency Vehicle / Safety Lookout / Shore Diver
Standby Diver / Other

SECTION 4: EQUIPMENT DETAILS (Fill out this section ONLY if Equipment was a Factor)

(FOR A SERIOUS ACCIDENT KEEP THE EQUIPMENT AS IT WAS AT THE TIME OF THE ACCIDENT)

Basic Snorkel or Dive Equipment: Please only tick items which were a factor in the Accident
Mask / Snorkel / Fins
Essential Dive Equipment: Please only tick items which were a factor in the Accident
ABLJ / Buoyancy Compensator / Dry Suit / Dump Valve (Dry Suit)
Dump Valve (BC) / Hood / Hose / Inflation Valve
Pressure Gauge / Regulator / Regulator Mouthpiece / Weights (Integrated System)
Weight Belt / Under Suit / Semi-Dry Suit / Wetsuit
Other
Useful Equipment: Please only tick items which were a factor in the Accident
Ankle Weights / Camera / Compass / Dive Computer
Gloves / Knife / Lifting Bag / SMB
Tools / Torch / Others
Boat Equipment: Please only tick items which were a factor in the Accident
Capsize / Engine Failure / Dirty Fuel / Out of Fuel
Boat Malfunction / Boat Swamping / VHF Radio / Electronics Failure
Winch Handle / Trailer / Bungees / Ropes
Propeller / Other (Specify)

DETAILS OF EQUIPMENT WHICH WERE A FACTOR IN THE ACCIDENT

Equipment: If Equipment Failure or Malfunction was implicated in this Accident please provide details
ITEM
Make
Model
Serial Number
Approx Age
Service History
Equipment: If Equipment Failure or Malfunction was implicated in this Accident please provide details
ITEM
Make
Model
Serial Number
Approx Age
Service History

SECTION 5: DETAILS OF INDIVIDUALS INVOLVED

REPORTER’S NAME / CFT NO
EMAIL ADDRESS / PHONE NO:

PLEASE FILL OUT THE FOLLOWING SECTIONS FOR EACH INDIVIDUAL INVOLVED IN THE ACCIDENT

PERSON A

NAME: / CLUB:
CFT NO: / QUALIFICATION:
PHONE NO: / YEARS DIVING:
ADDRESS / MEMBERSHIP STATUS
Role in Accident / AGE: <35; 35 – 50; >50
GENDER / DIVES THIS YEAR

PERSON B

NAME: / CLUB:
CFT NO: / QUALIFICATION:
PHONE NO: / YEARS DIVING:
ADDRESS / MEMBERSHIP STATUS
Role in Accident / AGE: <35; 35 – 50; >50
GENDER / DIVES THIS YEAR

PERSON C

NAME: / CLUB:
CFT NO: / QUALIFICATION:
PHONE NO: / YEARS DIVING:
ADDRESS / MEMBERSHIP STATUS
Role in Accident / AGE: <35; 35 – 50; >50
GENDER / DIVES THIS YEAR

PERSON D

NAME: / CLUB:
CFT NO: / QUALIFICATION:
PHONE NO: / YEARS DIVING:
ADDRESS / MEMBERSHIP STATUS
Role in Accident / AGE: <35; 35 – 50; >50
GENDER / DIVES THIS YEAR

Dive Officer of the Day Accident Log

(Use continuation sheets if necessary)

Restrict information to a factual account of the Accident with supporting information. It is inappropriate to include opinions, corrective actions or recommendations.

State details of first aid given

Name of D.O.D: ______

Signature of D.O.D: ______

Person (or Persons) Involved Accident Log

(Use continuation sheets if necessary)

Restrict information to a factual account of the Accident with supporting information. It is inappropriate to include opinions, corrective actions or recommendations.

State details of first aid given

Name of Reporter: ______

Signature of Reporter: ______

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