ARTC Event Summary Report

• Report Reference Number (only enter if known)

EVENT DETAILS

• Relates to:

  WHS

  Environment

  Rail Safety

• Event Type:

  Near Miss

  Incident

  Hazard

  Improvement

• Enter a Date and Time

  Date
• Location/Kilometres
  Address

EVENT DESCRIPTION AND ACTION TAKEN

• Description:

• add photos

  Media

• Immediate Actions/Controls taken/Solutions identified:

• Fatal & Severe Risk

  Select Vehicle Accidents Manual Handling Struck by Rail Traffic Rail Traffic Collision Struck by Mobile Plant Contact with Electricity Hazardous Chemicals, Hot Materials & Confined Spaces Crushed by Crane or lifted load Fall from Height Contractor Management Other

  • Vehicle Accidents
  • Manual Handling
  • Struck by Rail Traffic
  • Rail Traffic Collision
  • Struck by Mobile Plant
  • Contact with Electricity
  • Hazardous Chemicals, Hot Materials & Confined Spaces
  • Crushed by Crane or lifted load
  • Fall from Height
  • Contractor Management
  • Other

• Reported by:

• Team / Project:

CORRECTIVE ACTIONS

• Corrective Actions, by whom and due date:

CONFIRM NOTIFICATIONS COMPLETED (where required)

• Network Control (TCR #): or NA

• Injury (Injury Hotline Ref # / Employee Notification): or NA

• External (eg Environment, WHS) or NA

INITIAL CLASSIFICATION

• Event Severity (Actual)

  Significant (Level 1)

  Major (Level 2)

  Minor (Level 3)

  Negligible (Level 4)

• Event Severity (Potential)

  Significant (Level 1)

  Major (Level 2)

  Minor (Level 3)

  Negligible (Level 4)

• Is Investigating Commencing

  Yes (Event Severity 1, 2 and 3 - Incident & Near Miss Only

  Nil Required (Event Severity 4 and Hazards)

• Injury Classification:

  Lost Time Injury

  Medically Treated Injury

  First Aid Injury

• Environment Non-Conformance Type:

  EIA/EMP

  License/Permit

  Policy/Procedure

  Regulation

• Leader Approval (name):

• Team/Project:

• Date & Time:

  Date

Submit completed forms, including any attachments (photos, documents) to:

• (Hunter level 1/2/3) internalincidentalert@artc.com.au (Hunter level 4) hv-sct@artc.com.au

• (Inland) inlandrailsafetyteam@artc.com.au

• (Interstate) hazard@artc.com.au

• (Other) safetymatters@artc.com.au