Incident Report and Investigation Form

The South Australian Mining and Quarrying Occupational Health and Safety Committee

Promoting Work Health and Safety in the Workplace This workplace industry safety resource is developed and fully funded by the Mining and Quarrying Occupational Health and Safety Committee (MAQOHSC).

Disclaimer

IMPORTANT: The information in this guide is of a general nature, and should not be relied upon as individual professional advice. If necessary, legal advice should be obtained from a legal practitioner with expertise in the field of Work Health and Safety law (SA).

Although every effort has been made to ensure that the information in this guide is complete, current and accurate, the Mining and Quarrying Occupational Health and Safety Committee, any agent, author, contributor or the South Australian Government, does not guarantee that it is so, and the Committee accepts no responsibility for any loss, damage or personal injury that may result from the use of any material which is not complete, current and accurate.

Users should always verify historical material by making and relying upon their own separate inquiries prior to making any important decisions or taking any action on the basis of this information.

Creative Commons

This work is licenced under Creative Commons Attribution – Non Commercial 4.0 International Licence. The licence is available to view at http://creativecommons.org/licenses/by-nc/4.0/

This creative commons licence allows you to copy, communicate and or adapt our work for non- commercial purposes only, as long as you attribute the work to Mining and Quarrying Occupational Health and Safety Committee and abide by all the other licence terms therein.

ISBN 978-1-925361-68-1

Contact information

Mining and Quarrying Occupational Health and Safety Committee (MAQOHSC) World Park A Building Level 4, 33 Richmond Road Keswick SA 5035 Phone: (08) 8204 9842 Email: [email protected] Website: www.maqohsc.sa.gov.au

June 2017 Insert Company Logo Incident Report and Investigation Form Here Template

Incident Type and Subtype: Please Tick Incident Report No:

Category Health / Safety  Environment  Community  Quality (including Damage)  Complaint  Damage  Promotion Production Loss  Sub Injury  Air  Blasting  Light Vehicle  Category Near Miss  Water  Noise  Mobile Equipment  Security Breach  Ground  Odour  Fixed Plant  Isolation Breach  Flora/Fauna  Lighting  Tools  Theft  Cultural/Heritage  Dust  Other  Fire 

Description of the Incident (add detailed incident description, drawings and photos as required)

Date of Incident: ______Time: ______Date Reported: ______Time: ______Reported to: ______Incident Location: ______Description of Incident: ______Equipment Involved: ______What was the task / activity being conducted at the time? ______Immediate Action Taken: ______

Person(s) Involved

Name: ______Date of Birth: ______

Employment type: Permanent  Casual  Labour Hire  Other  ______

Employer: ______Employee No: ______

Contractor: Yes  No  Length of employment: ______Years ______Months

Name: ______Date of Birth: ______

Employment type: Permanent  Casual  Labour Hire  Other  ______

Employer: ______Employee No: ______

Contractor: Yes  No  Length of employment: ______Years ______Months

Witnesses:______

Work Health and Safety Resource Manual Page 1 of 7 Insert Company Logo Incident Report and Investigation Form Here Template

Was drug and alcohol testing conducted / required? Yes  No 

Personal Injury Yes  No  Person 1______Person 2______Treatment: None  First Aid  Doctor / Hospital  First Aid Given by:______Details:______

Location of Injury:

Head / Face  Arm  Leg  Trunk  Back / Neck 

Eye  Shoulder  Thigh  Collar bone  Neck 

Nose  Upper arm  Knee  Ribs  Upper back 

Mouth  Elbow  Shin  Sternum  Middle back 

Teeth  Fore arm  Calf  Internal organs  Lower back 

Ear  Hand  Ankle  Lower abdomen  Spine 

Cheek  Finger(s)  Foot  Hips 

Chin  Thumb  Toe(s)  Groin 

Fore head  Palm 

Top of head 

Back of head 

Other: ______Nature of injury:

Laceration  Amputation  Fracture  Dislocation  Spinal injury  Sprain / Bruise   Poison  Foreign body  Head injury  strain Burn  Exposure  Open wound  Nerve damage  InternaI injury 

Other: ______

Mechanism of injury:

Fall from height  Fall same level  Hit object with body part  Hit by moving object 

Repetitive movement  Mucular stressors  Contact with electricity  Vehicle accident 

Exposure to heat / cold  Contact with Chemical  Slip, trip  Bites, stings 

Vibration  Noise exposure  Radiation exposure  Biological 

Contact with moving part  Mental stressors 

Other: ______

Similar injury suffered previously? Yes  No 

If Yes, when?______Treatment provided: ______

Work Health and Safety Resource Manual Page 2 of 7 Insert Company Logo Incident Report and Investigation Form Here Template Returned to normal duties? Yes  No  Alternative duties: ______

Ranking

Actual outcome: Near Miss  Minor  Moderate  Serious  Major  Catastrophic 

Potential Minor  Moderate  Serious  Major  Catastrophic  Consequence:

Likelihood Rare  Unlikely  Possible  Likely  Certain 

Risk Matrix Legends Rating Safety Health Environment Single minor injury to one Issues of non-continuous nature with person. Reversible health effects of minor 1 promptly reversible impact or First aid or no treatment concern only requiring minor first aid Minor consequence (e.g. within shift). Low- required. treatment. level incident, site contained. No lost time. Medically treated injury. Issues of a non-continuous nature and Reversible health effects of concern 2 Reversible injury. minor impact and consequence. Low- that results in medical treatment but Moderate Does not lead to restricted level incident, site contained. Short does not lead to restricted duties. duties. term reversible (e.g. within days). Issues of a continuous nature - Reversible injury or moderate Severe but reversible health effects. limited impact and consequence 3 irreversible impairment. Less Results in a lost time illness of less Incident resulting in some site Serious than 10 days lost time. than 10 days. contamination. Medium term recovery impact. Compliance issue with large fine, Severe irreversible damage to media attention. Serious harm not 4 Severe and irreversible health one or more persons. Lost Time immediately recovered. Significant Major effects or disabling illness. Injury greater than 10 days site contamination or off-site impact. Long term recovery. Issues of a continuous nature with 5 Fatality. Permanent disabling Life threatening or permanently major long-term impact and potentially Catastrophic injuries disabling illness. serious consequences

Descriptor Description Suggested Frequency

Recurring event during the lifetime of a project / operation e.g. More than Almost certain The event is expected to occur once per month Event that may occur frequently during the lifetime of a project / operation Likely The event will probably occur e.g. At least once per year Event that may occur during the lifetime of a project / operation e.g. Once Possible The event should occur in 3 years Event that is unlikely to occur during the lifetime of a project / operation e.g. Unlikely The event could occur Once in 10 years The event may occur only in Event that is very unlikely to occur during the lifetime of a project / Rare exceptional circumstances operation e.g. Once in 15 years

Regulatory Notification Requirement Yes  No 

SafeWork SA  Dept. State Development (DSD)  Environment Protection Authority (EPA)  Regulatory Body: Office of the Technical Regulator (Electrical) 

Date Reported: ____/_____/______Time: ______Reported by: ______

Person reported to (Name): ______

Information Provided: ______

______

Information Requested: ______

______

Instructions given by Regulator: ______

______

Investigation Team Members

Name: Role: Signature:

Incident Analysis

System Factor In Place Absent / Failed / Inadequate People: (check training records and competency, review previous incidents) (following instruction, fitness for work, attitude, complacency, inexperienced, rushing, risk assessment conducted prior to commencing task)

Environment (check surroundings, access, egress, hostile environment, work space, housekeeping, noise, dust, confined areas, weather, poor visibility, task unfamiliarity, uneven ground, wildlife)

Equipment and Materials (check chemicals, tooling and equipment) (check suitability, fit for purpose, approved for site use, design, modifications, suitability, condition, guarding, maintenance records)

Methods of Work (check procedures, permits, training, instructions, Take 5, Job Hazard Analysis, risk assessments, licences)

Organisation (check systems of work, training provided, supervision, communications, instructions given, personal protective equipment provided, culture, pressures)

Failures: Why?

Recommendations to prevent recurrence: Hierarchy of Control (Elimination, Subsitution, No. Action Description By Whom By When Engineering, Isolation, Administration, Personal Protective Equipment)

Incident review and sign off:

Role: Name: Signature: Date:

Person/s involved

Immediate Supervisor

Area Manager Health and Safety Representative Health and Safety Committee Work Health and Safety Manager / Coordinator Quarry / Mine Manager

Evaluation: Comment: Conducted by: Date: (to be conducted 3 months after incident occurrence)

Have all corrective actions been implemented?

Has the incident and corrective actions been communicated to personnel and key stakeholders?

Have any similar incidents or near misses occurred?

Do the implemented controls appear to be effective?

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