Anzac Ave - Arrow Incident Report

• Date of this Report

  Date

• Reported by and contact number

• Incident Date and Time

  Date

• Incident Type

  Select T1 - Notifiable Injury / Illness – as defined by the HSWA Act (notification as per Arrow procedure HSE4.1) T2 - Lost Time Injury (LTI) – an injured employee is absent from work for one complete day / shift following the day of the accident. T3 - Medical Treatment Injury (MTI) – any work injury that involves neither lost time injury nor restricted work (light duties) but which requires treatment by a medical physician. T4 - Alternative Work Injury (AWI) – a work related injury which results in alternative duties being provided for the injured person and could be a result of any of the above incident types. T5 - Minor Harm Incident – first aid treatment with no lost time. T6 - Incident as a result of existing medical condition or injury.

  • T1 - Notifiable Injury / Illness – as defined by the HSWA Act (notification as per Arrow procedure HSE4.1)
  • T2 - Lost Time Injury (LTI) – an injured employee is absent from work for one complete day / shift following the day of the accident.
  • T3 - Medical Treatment Injury (MTI) – any work injury that involves neither lost time injury nor restricted work (light duties) but which requires treatment by a medical physician.
  • T4 - Alternative Work Injury (AWI) – a work related injury which results in alternative duties being provided for the injured person and could be a result of any of the above incident types.
  • T5 - Minor Harm Incident – first aid treatment with no lost time.
  • T6 - Incident as a result of existing medical condition or injury.

• If Notifiable Injury / Illness record lost time

• INSTRUCTIONS:
  -------------------------------------
  1. Answer the applicable questions below.
  2. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority and due date.
  3. Complete audit by providing digital signature.
  4. Share your report by exporting as PDF, Word, Excel or Web Link.

GENERAL INFORMATION

• Person/s Directly Involved

• Employer

• Trade

• Location of Incident

• Name of Witness (if any)

• Photo Attached?

  Yes

  No

• Worksafe NZ Notified?

  Yes

• What Occurred? (Record all facts prior to and including the accident / incident. Include conditions of work area.)

• Stage of the Project

  Select Demolition Structure Internal Finishes Mobilisation Cladding External Finishes Foundations Roofing De-mobilisation Ground Works / Excavation Services Installation

  • Demolition
  • Structure
  • Internal Finishes
  • Mobilisation
  • Cladding
  • External Finishes
  • Foundations
  • Roofing
  • De-mobilisation
  • Ground Works / Excavation
  • Services Installation

• Critical Risk Activity Involved in Incident

  Yes

  No

• What Critical Risk Activity was involved?

  Select Access / working platforms above 5m Working in and around mobile plant Existing services/underground buried services Working in remote locations / lone working Hazards in premises controlled by others Working with Asbestos/Asbestos Containing Material (ACM) Exposure to asbestos Violence at work Working at height Confined Spaces Energy Isolation Excavation works Demolition works Crane operations (heavy lifting) Working with temporary works Working with Electricity Traffic Management

  • Access / working platforms above 5m
  • Working in and around mobile plant
  • Existing services/underground buried services
  • Working in remote locations / lone working
  • Hazards in premises controlled by others
  • Working with Asbestos/Asbestos Containing Material (ACM)
  • Exposure to asbestos
  • Violence at work
  • Working at height
  • Confined Spaces
  • Energy Isolation
  • Excavation works
  • Demolition works
  • Crane operations (heavy lifting)
  • Working with temporary works
  • Working with Electricity
  • Traffic Management

• Nature of Injury or Disease

  Select Burns Sprain or strain Foreign body Open wound Hearing loss Fracture of spine Other fractures Amputation Dislocations Disease Laceration / cut Bruising or crushing Superficial (scratch/abrasion) Poisoning / toxic effect Gradual process injury Puncture wound Multiple injury Internal injury Head injury Fatal

  • Burns
  • Sprain or strain
  • Foreign body
  • Open wound
  • Hearing loss
  • Fracture of spine
  • Other fractures
  • Amputation
  • Dislocations
  • Disease
  • Laceration / cut
  • Bruising or crushing
  • Superficial (scratch/abrasion)
  • Poisoning / toxic effect
  • Gradual process injury
  • Puncture wound
  • Multiple injury
  • Internal injury
  • Head injury
  • Fatal

• Description of injury

• Treatment of injury

  Nil

  First aid only

  Doctor

  Hospitalised

• Name of treatment provider

• Contributing Factor/s (please select from each heading to establish all contributing factors)

• Personal Factors

  Select 1. Rushing Work 2. Lack of Adequate Training of the Task 3. Lack of Attention 4. Poor Perception of H&S Risk 5. Violation of H&S Rules 6. Fatigue 7. Distraction 8. Horse Play 9. Excessive Demands 10. Lack of Competence (skill, knowledge, experience) 11. Purchase and Use of Substandard Plant, Work Equipment or Materials

  • 1. Rushing Work
  • 2. Lack of Adequate Training of the Task
  • 3. Lack of Attention
  • 4. Poor Perception of H&S Risk
  • 5. Violation of H&S Rules
  • 6. Fatigue
  • 7. Distraction
  • 8. Horse Play
  • 9. Excessive Demands
  • 10. Lack of Competence (skill, knowledge, experience)
  • 11. Purchase and Use of Substandard Plant, Work Equipment or Materials

• Work Factors

  Select 12. Poor or Lack of Supervision 13. Poor Maintenance of Plant and Work Equipment 14. Poor Communication 15. Unsuitable Safe Work Method Statement / TA 16. Poor Hazard Identification & Risk Assessment 17. Unsuitable Control of Hazardous Materials 18. Poor Emergency Response 19. Poor Plant and Equipment Design 20. Provision and Use of PPE 21. Poor Job Planning

  • 12. Poor or Lack of Supervision
  • 13. Poor Maintenance of Plant and Work Equipment
  • 14. Poor Communication
  • 15. Unsuitable Safe Work Method Statement / TA
  • 16. Poor Hazard Identification & Risk Assessment
  • 17. Unsuitable Control of Hazardous Materials
  • 18. Poor Emergency Response
  • 19. Poor Plant and Equipment Design
  • 20. Provision and Use of PPE
  • 21. Poor Job Planning

• What was the cause of the incident? (please note immediate and root cause below):

• Was the injured person trained in the task / activity being carried out at the time?

  Yes

  No

• Experience at their present job:

  Select 6 months or less 6 months to 4 years More than 4 years

  • 6 months or less
  • 6 months to 4 years
  • More than 4 years

• Preventative Action (describe controls / methods to minimise risk of recurrence below)

• Recommended Corrective Action

  Select Remove and replace unsuitable plant and work equpment. Improved supervision for the individual Improved supervision for the group and work activity Review and improve Safe Work Method Statement Carry out a revised hazard identification, risk assessment and risk control process Introduce daily pre start toolbox meetings Improve communication between all workers, groups and contractors Retrain personnel

  • Remove and replace unsuitable plant and work equpment.
  • Improved supervision for the individual
  • Improved supervision for the group and work activity
  • Review and improve Safe Work Method Statement
  • Carry out a revised hazard identification, risk assessment and risk control process
  • Introduce daily pre start toolbox meetings
  • Improve communication between all workers, groups and contractors
  • Retrain personnel

COMPLETION

• Discuss any of the above selected recommendations with all those involved at a post incident toolbox meeting.

• Acceptance of report by injured person:

  Sign

• Action to be completed by (Name and Signature)

  Sign

• Closed Out (agreed actions have been completed and this situation is now satisfactory)

• Project Director / Project Manager / Office Manager as applicable

  Sign

• Send to HS&E Coordinator & Site Team<br>Note: Refer to Mandatory Requirements for Reporting of Incidents for further reporting requirements.

  Yes