Safety and Health Incident Report Form

Safety, Health and Wellbeing Incident Report Form This form is to be completed for all Safety and Health incidents

INCIDENT REPORTING DETAILS:

Date of Incident: / / Time of incident: (please use 24hr format)

Incident Reported Name: MRWA Employee Contractor (name)______by: Member of Public Sub-Contractor (name)______

Project Relation Construction Project Name: Contract No: Incident Report No: (if applicable): Project Maintenance Project Manager (PM) Name: PM Email: Location of Incident: Directorate: Region: Branch (if applicable): (Where applicable enter either facility / building Road Name: Road Number: SLK: GPS Location (GDA94): details and/or road location details) DAC Regional Office Depot (Specify):______Floor: HVS (Specify): On Road ______MEB Staff(Wardens/Inspect Laboratory ors) Outcome of the Lost Time Injury (1 Incident Notification: incident: For serious incidents: full shift or longer lost) Actual Outcome of Moderate or Potential Outcome of High or Very High Medically Treated Main Roads: SHW Branch to be notified within 24 hours Injury Contractors: Main Roads Project/Contract Manager to be notified within 24 hours First Aid Injury Date notified: / / Near Miss (No damage to property or injury to personnel) Damage (Damage to property or assets) DESCRIPTION OF INCIDENT: Type of incident: Safety Health

Document No. D15#497567 1 of 7 (Check Appropriate Slips / Trips / Falls Ergonomics: e.g. RSI, back pain etc. Boxes, can be Plant and Asbestos multiple selections) Equipment Dust Cranes and Lifting Bites / Stings Working at Height Chemical Exposure Confined Space Noise Exposure Please clarify if Vehicles and required: Alcohol and Drugs Driving Fatigue Traffic Needle stick Management Hand held tools Vibration Electrical Viral/Bacterial Mental Health Excavation/Trenching Health (e.g. asthma, heart attack) Hazardous Other (specify):______Substances Hot Work Other: Does this incident Foreign Objects Process Loss involve a member of Injections Production Loss the public? (Hydraulic, Damage Reputation pneumatic, etc…) Disruption to a community Ergonomics: Exposure to Legal Liability Musculoskeletal Acute e.g. Sprain, Security Threat Strain etc. Other (specify):

______

Yes No Incident Description: (Step by step account of the incident)

What are the existing controls in place? (e.g. spill kits, bunding, clearing area pegged, PPE worn, machine guarding) Responsible Person Corrective Actions Action Description Due Date Completion Date and Role

2 Control(s) put in place before and after the incident to Rectify, Contain or Remedy the situation

Employee Type: (MRWA Employee OR Contractor OR Member of Name: Job Title(s): Public) (If applicable include Contractor name) 1. 1. 1. Persons Involved 2. 2. 2. 3. 3. 3. 4. 4. 4. What was the actual Insignificant Minor Moderate Major Catastrophic consequence? (Refer to Appendix Complete Incident Complete Incident 5 Why (MTI), ICAM or ICAM or equivalent ICAM or equivalent A below) Report Report equivalent investigation investigation investigation (LTI) What was the Potential Low Medium High Very High Outcome? Complete Incident 5 Why or equivalent ICAM or equivalent ICAM or equivalent Report investigation investigation investigation What is the Risk Rating after controls Low Medium High Very High are put in place? Is this incident Yes No Report made by: required to be reported to Reference No: Date Report Made: / / WorkSafe or INJURY DETAILS (only applicable if the incident resulted in personal injury): How was the injury Fall from a height Exposure to noise (incl long term) sustained? Slips and Trips Contact with chemical or substance (Mechanism of Vehicle incident Cuts, abrasions and lacerations Injury) Musculoskeletal Contact to heat and cold (sudden movement, Contact with electricity sharp pains) Insect bites and stings Repetitive Treatment given & Name: Job Title: assessed by: Type of treatment None required First Aid Medical (Doctor/Hospital) Emergency Department given: Work Related Injury This is a work related injury This is a non-work related injury Bodily location of Eye Shoulders and Internal organs the injury: Face arms Trunk (other than back and excl internal) (Please select all Ear Hands and fingers General and unspecified locations that apply) Neck Back Comments:

DETAILS OF PERSON COMPLETING THIS FORM, REVIEW AND SIGNOFF

Document No. D15#497567 3 of 7 Name: Signature: Form completed by: Date: / / Role:

Contractor Review and Sign Off (construction / maintenance)

Level 1. Name: Signature: Date: / / Role:

Main Roads Review and Sign Off (MRWA employee incident)

Level 1. Name: Signature: Date: / / Role: Level 2. Name: Signature: Date: / / Role: Level 3. Name: Signature: Date: / / Role:

Level 1. (Contractor) – Project Manager, Safety Manager or equivalent responsible person Level 1. (MRWA employee incidents) – Project/Contract Manager/Line Manager or equivalent eg: Superintendents Rep Level 2. (MRWA employee incidents) – Project Director or Regional Manager or Branch Manager Level 3. (MRWA employee incidents) – Executive Director or delegate

Appendix A – Likelihood / Consequence and Risk Ranking Tables

CONSEQUENCE

LIKELIHOOD Insignificant Minor Moderate Major Catastrophic

Almost Certain Low High High Very High Very High

Likely Low Medium High Very High Very High

Possible Low Low Medium High High

Unlikely Low Low Low Medium High

Rare Low Low Low Low Medium

4 DESCRIPTION OF RISK Risk Rating LEVEL OF RISK

Low Risk is generally acceptable

Risk is acceptable with adequate controls. Medium Treatment action plan required if consequence is Catastrophic

Risk may be acceptable with adequate High controls. Treatment action plan required to reduce risk level further where possible.

Risk is generally not acceptable. Treatment Very High action plan required to reduce the risk.

QUALITATIVE MEASURES OF LIKELIHOOD Rating Description Frequency Rare The event may Less than once occur only in every 50 years exceptional circumstances Unlikely The event could Once every 10-50 occur at some time years Possible The event might Once every 1-10 occur at some time years Likely The event will More than once per probably occur in year most circumstances Almost certain The event is More than once per expected to occur month in most circumstances

Document No. D15#497567 5 of 7 QUALITATIVE MEASURES OF CONSEQUENCE Rating Health & Safety Transport Services Financial Reputation & trust (Political, stakeholders & community) Business Operations Legal & Compliance Insignificant No treatment required  Service infrastructure receives minimal damage, minor rectification required. Service/s only temporarily unavailable or remain operational.  Minor impact to customers e.g. minor drop in patronage or minor congestion. Greater of:  Less than $100,000; or  Deviation from project budget within + 5%.  Isolated local community or individual’s issue-based concerns.  Low profile media attention.  Some insignificant delays to business activities.  Up to 5% variation in KPI or objective.  Guidance required for legal / compliance issues, managed through routine procedures.  Legal action unlikely. Minor First aid treatment required  One or a number of services are unavailable or operating with restrictions but can be resumed within acceptable timeframes.  Short term impact to customers e.g. short term drop in patronage or isolated congestion. Greater of:  $100,000 to $1 m; or  Deviation from project budget between 610%.  Local community impacts & concerns.  Occasional once off negative media attention.  Trust issues raised.  Minor delays to business activities.  5% to 10% Variation in KPI or objective.  Complex legal/non-compliance issue to be addressed.  Legal action and/or public liability claim possible. Moderate Medical treatment required or Lost Time Injury  One or a number of services, including critical services, are unavailable for an extended length of time.  Moderate impact to customers e.g. complaints and moderate drop in patronage or moderate level of short-term congestion. Greater of:  $1 m to $10 m; or  Deviation from project budget between 1020%.  Sectional community impacts & concerns publicly expressed.  Increased negative media attention.  Loss of confidence & trust by community & stakeholders in Agency processes & capability.  Ministerial concern.  Some moderate delays to business activities.  10% to 25% Variation in KPI or objective. 6  One or more projects is significantly impaired.  Non-compliance/s with regulation and/or probity infringements, which may result in some processes repeated.  Legal action probable. Major Single fatality or major injuries or severe permanent disablement  A number of critical services are cancelled, with extensive rectification required before resumption of services.  Non-critical service infrastructure is not operational and cannot be rectified.  Substantial impact to customers e.g. major drop in patronage or major level of congestion. Greater of:  $10 m to $30 m; or  Deviation from project budget between 2030%.  Considerable & prolonged community impact & dissatisfaction publicly expressed.  Consistent negative media attention.  Criticism & loss of confidence / trust by community & stakeholders in Agency processes & capability.  Ministerial intervention.  Major delays to activities.  25% to 50% Variation in KPI or objective.  One or more critical programs or projects cannot be delivered.  Major non-compliance with regulation, which may result in termination of a process or imposed penalties.  Legal action taken against Agency and/or major public liability claim or potential class action. Catastrophic Multiple fatalities  Critical service infrastructure is not operational and cannot be rectified.  Significant impact to customers e.g. sustained drop in patronage or sustained level of significant congestion. Greater of:  Greater than $30 m; or  Deviation from project budget > 30%.  Significant adverse community impacts & condemnation.  Extreme negative media attention.  Consistent ongoing community loss of confidence & trust in Agency capabilities and intentions.  Government intervention.  Activities ceased.  More than 50% Variation in KPI or objective.  Multiple critical programs or projects cannot be delivered.  Major non-compliance with legislation and/or regulation which may result in criminal charges and/or loss of required accreditation.  Significant legal consequence/s class action against agency.

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