AWX-Incident Report Form

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

RESPONSIBLE SUPERVISOR TO COMPLETE WITHIN 24 HOURS OF OCCURRENCE

• Other applicable documents:
  G-421 Incident investigation Procedure
  G-223 Incident investigation Report
  G-261 Incident Statement Report
  G-051 Environmental Incident Details Form
  G-264 HSEQ Incident Investigation and Response Activity Trigger Guideline
  G-412 Incident Report and Investigation Flow Chart
  G-405 Serious Material/ Environmental Harm Guideline

• All incidents to be reported within 24 hours of occurrence.

• CLIENT NAME:

• SITE ADDRESS:

• LOCATION OF INCIDENT ON SITE:
  Address

• incident Type

  Select Damage / Loss Environmental Injury Near Miss Hazard Non-Statistical

  • Damage / Loss
  • Environmental
  • Injury
  • Near Miss
  • Hazard
  • Non-Statistical

OCCURRENCE DETAILS

• Incident date

  Date

• Incident time (24 hr)

  Date

• Reported date

  Date

• Reported time (24 hr)

  Date

• Brief Description of Incident

• Name of person reported to

• Name of person making report

• Client incident report no.

• Location of incident

• Hazard classification

  Select Biological Chemical Electrical Environmental Erogonomic Mechanical Physical Procedural Psychological Radiation

  • Biological
  • Chemical
  • Electrical
  • Environmental
  • Erogonomic
  • Mechanical
  • Physical
  • Procedural
  • Psychological
  • Radiation

PERSONNEL DETAILS

• Personnel involved

• Gender

  Male

  Female

• Date of birth (dd/mm/yy)

  Date

• Subcontractor employee

  Yes

  No

  N/A

• Subcontractor business name

• Persons normal job classification

• Job classification at time of incident

SHIFT DETAILS

• Shift

  Day

  Night

  Rostered off

  Other

• Normal shift length (hrs)

• Hours into shift

  0-25%

  26-50%

  51-75%

  76-100%

• No. shift into roster

• Roster length (ie. 7 days on / 7 off or 3 weeks on / 1 off)

INJURY CLASSIFICATION

• Injury classification

  Select ADI (alternate duties injury) FAI (first aid injury) FAT (fatality) LTI (lost time injury) MTI (medical treatment injury) NOI (no injury)

  • ADI (alternate duties injury)
  • FAI (first aid injury)
  • FAT (fatality)
  • LTI (lost time injury)
  • MTI (medical treatment injury)
  • NOI (no injury)

INJURY DETAILS

• Bodily location / disease

  Select Eye Ear Face head(Not eye /ear /face) Neck Back Trunk Shoulders & Arms Hands & Fingers Hips & Legs Feet & Toes Internal Organs Multiple Locations General / Unspecified Locations Dislocations

  • Eye
  • Ear
  • Face
  • head(Not eye /ear /face)
  • Neck
  • Back
  • Trunk
  • Shoulders & Arms
  • Hands & Fingers
  • Hips & Legs
  • Feet & Toes
  • Internal Organs
  • Multiple Locations
  • General / Unspecified Locations
  • Dislocations

• Nature of injury / disease

  Select Fractures (Excl. Vertebra) Fracture of Vertebra Internal Injury of Chest etc Sprains & Strains intracranial Injury Superficial Injury Traumatic Amputation Open Wound, no Amputation Bruns Contusion & Crush Injury Foreign Body Effects of Weather (Exposure) Injury to Nerves / Spinal Cord Poisoning & Toxic Other & unspecified Injuries Multiple Injuries Damage to Artificial Aids Nervous system Deafness Eye Disorders Dermatitis & Eczema Muscle & Tendon Disorders Musculoskeletal System Digestive System Skin & Subcutaneous Tissue Hernia Circulatory System Infectious & Parasitic Diseases Respiratory System Circulatory System Infection & Parasitic Diseases Respiratory System Other Diseases Cancer & Neoplasms Mental Disorders

  • Fractures (Excl. Vertebra)
  • Fracture of Vertebra
  • Internal Injury of Chest etc
  • Sprains & Strains
  • intracranial Injury
  • Superficial Injury
  • Traumatic Amputation
  • Open Wound, no Amputation
  • Bruns
  • Contusion & Crush Injury
  • Foreign Body
  • Effects of Weather (Exposure)
  • Injury to Nerves / Spinal Cord
  • Poisoning & Toxic
  • Other & unspecified Injuries
  • Multiple Injuries
  • Damage to Artificial Aids
  • Nervous system
  • Deafness
  • Eye Disorders
  • Dermatitis & Eczema
  • Muscle & Tendon Disorders
  • Musculoskeletal System
  • Digestive System
  • Skin & Subcutaneous Tissue
  • Hernia
  • Circulatory System
  • Infectious & Parasitic Diseases
  • Respiratory System
  • Circulatory System
  • Infection & Parasitic Diseases
  • Respiratory System
  • Other Diseases
  • Cancer & Neoplasms
  • Mental Disorders

• Has a GP (Doctor) been consulted

  Yes

  No

  N/A

EQUIPMENT AND PROPERTY DAMAGE

• Damage to (What equipment / property was damaged?)

  Select Ancillary Bogger Bobcat Buildings/Infrastructure Cabolter Change Vehicle Crane Crusher Dozer Drill Rig Drill Rig - Long Hole Dump Truck Excavator Forklift Front End Koader Generator Set Grader Hand Tool Hiab Integrated Tool Carrier Jumbo Light Vehicle Moxy Power Tool Scissor Lift Scraper Screening Plant Service Truck Shotcrete Rig Roller Telescopic Handler Third party equip/prop damage Truck (Other) Water Truck Welder No equip. or property damage Other

  • Ancillary
  • Bogger
  • Bobcat
  • Buildings/Infrastructure
  • Cabolter
  • Change Vehicle
  • Crane
  • Crusher
  • Dozer
  • Drill Rig
  • Drill Rig - Long Hole
  • Dump Truck
  • Excavator
  • Forklift
  • Front End Koader
  • Generator Set
  • Grader
  • Hand Tool
  • Hiab
  • Integrated Tool Carrier
  • Jumbo
  • Light Vehicle
  • Moxy
  • Power Tool
  • Scissor Lift
  • Scraper
  • Screening Plant
  • Service Truck
  • Shotcrete Rig
  • Roller
  • Telescopic Handler
  • Third party equip/prop damage
  • Truck (Other)
  • Water Truck
  • Welder
  • No equip. or property damage
  • Other

• Damage category

  Select ancillary business loss heavy equipment light vehicle

  • ancillary
  • business loss
  • heavy equipment
  • light vehicle

• Asset / Plant No.

• Estimated repair cost ($):

• Other costs ($)

NEAR MISS / HAZARD

• Potential for

  Select environmental impact equip / property damage financial loss high potential incident personal injury production loss other

  • environmental impact
  • equip / property damage
  • financial loss
  • high potential incident
  • personal injury
  • production loss
  • other

• Note: A High Potential incident is an undesired occurrence, which under slightly different circumstances, could have resulted in harm to people, damage to property or loss to process.

ENVIRONMENTAL IMPACT

• Impact to (What, if, was impacted during the incident?)

  Select air community flora - specie fauna - specie ground water heritage land no environmental damage marine surface water other

  • air
  • community
  • flora - specie
  • fauna - specie
  • ground water
  • heritage
  • land
  • no environmental damage
  • marine
  • surface water
  • other

• Pollutant (Nominate pollutant type)

• Quantity and Unit (circle) (if not know, please estimate)

• Kilograms

• Litres

• Tonnes

• Complete and attach G-051 Environmental Incident Details for all environmental incidents having a risk rating of L5 and above.

INVESTIGATION

• Identify system errors, basic and immediate cause and agency for all incidents below. All incidents >_M13 shall complete G-223 Incident Investigation Report.

• System errors (standards and procedures, resourcing, training, operational vs safety requirements, change management, planning)

  Select inadequate company standards inadequate work standards inadequate procedures inadequate training in procedures inadequate programs inadequate planning inadequate hazard / risk review inadequate control of hazard / risk inadequate resourcing/safety equipment safety vs operational conflicts other

  • inadequate company standards
  • inadequate work standards
  • inadequate procedures
  • inadequate training in procedures
  • inadequate programs
  • inadequate planning
  • inadequate hazard / risk review
  • inadequate control of hazard / risk
  • inadequate resourcing/safety equipment
  • safety vs operational conflicts
  • other

• Basic Cause(people and job factors)

  Select Abuse or misuse Excessive frustration Exposure to health harzards Exposure to temp extremes Fatigue Improper incentives Improper motivation Inadequate training/induction Inadequate instruction Inadequate maintenance Inadequate supervision Inadequate purchasing Inadequate work standards Inadequate equipment/tools Inadequate engineering Inadequate discipline Inappropriate aggression Injury / illness Lack of skill Lack of knowledge Lack of experience Mental stress Misunderstood instruction Non compliance to process Non compliance to permit Physical stress Physical incapacity Psychological Incapacity Physical disability Use of non-standard procedures Peer pressure Safety vs operational conflict Wear & tear Work overload Other

  • Abuse or misuse
  • Excessive frustration
  • Exposure to health harzards
  • Exposure to temp extremes
  • Fatigue
  • Improper incentives
  • Improper motivation
  • Inadequate training/induction
  • Inadequate instruction
  • Inadequate maintenance
  • Inadequate supervision
  • Inadequate purchasing
  • Inadequate work standards
  • Inadequate equipment/tools
  • Inadequate engineering
  • Inadequate discipline
  • Inappropriate aggression
  • Injury / illness
  • Lack of skill
  • Lack of knowledge
  • Lack of experience
  • Mental stress
  • Misunderstood instruction
  • Non compliance to process
  • Non compliance to permit
  • Physical stress
  • Physical incapacity
  • Psychological Incapacity
  • Physical disability
  • Use of non-standard procedures
  • Peer pressure
  • Safety vs operational conflict
  • Wear & tear
  • Work overload
  • Other

• Immediate Cause (substandard practices / acts / conditions)

  Select Congestion or restricted area Defective tools and equip Defective materials Excess illumination Excessive noise Excessive dust Explosion hazard Environmental conditions Fail to use PPE / use correctly Failure to secure Failure to isolate Failure to obey rules Failures to follow procedure Failure to warn Fire hazard Ground conditions Hazardous conditions Horseplay Improper speed Improper lifting Improper placement Improper loading Improper positioning Inattention Inadequate ventilation Inadequate warning system Inadequate guards Inadequate barriers inadequate illumination inadequate PPE inadequate design inadequate communication inadequate guarding inadequate storage inadequate inspection poor housekeeping radiation exposure removed safety devices surface gradient temperature extremes using drugs or alcohol using defective tools using defective equipment unauthorised use of equip other

  • Congestion or restricted area
  • Defective tools and equip
  • Defective materials
  • Excess illumination
  • Excessive noise
  • Excessive dust
  • Explosion hazard
  • Environmental conditions
  • Fail to use PPE / use correctly
  • Failure to secure
  • Failure to isolate
  • Failure to obey rules
  • Failures to follow procedure
  • Failure to warn
  • Fire hazard
  • Ground conditions
  • Hazardous conditions
  • Horseplay
  • Improper speed
  • Improper lifting
  • Improper placement
  • Improper loading
  • Improper positioning
  • Inattention
  • Inadequate ventilation
  • Inadequate warning system
  • Inadequate guards
  • Inadequate barriers
  • inadequate illumination
  • inadequate PPE
  • inadequate design
  • inadequate communication
  • inadequate guarding
  • inadequate storage
  • inadequate inspection
  • poor housekeeping
  • radiation exposure
  • removed safety devices
  • surface gradient
  • temperature extremes
  • using drugs or alcohol
  • using defective tools
  • using defective equipment
  • unauthorised use of equip
  • other

• Agency of incident (What was the action, activity, energy or substance that enabled the incident to occur? Generally this includes contact with / exposure to / fall from / failure of / hit by / impacted by ........something (agent) that contributed to incident)

  Select air pollutants biological agents behaviour corrosion cultural / heritage chemicals dust / particles effluent eletricity explosives erosion / weathering flora fauna falls from height falls from same level gas hit by moving object hit by stationery object hitting objects with body heavy vehicle heat / cold / temperature humidity hydrocarbons (fuel) hydrocarbons (oils) hazardous waste hazardous substances light vehicle mental stress mechanical vibration multiple mechanisms machinery / equipment noise physical agent physical stress radiation refuse / litter repetitive movement sediment slide or cave-in smoke tools variations in pressure vandalism wind water unspecified mechanisms other

  • air pollutants
  • biological agents
  • behaviour
  • corrosion
  • cultural / heritage
  • chemicals
  • dust / particles
  • effluent
  • eletricity
  • explosives
  • erosion / weathering
  • flora
  • fauna
  • falls from height
  • falls from same level
  • gas
  • hit by moving object
  • hit by stationery object
  • hitting objects with body
  • heavy vehicle
  • heat / cold / temperature
  • humidity
  • hydrocarbons (fuel)
  • hydrocarbons (oils)
  • hazardous waste
  • hazardous substances
  • light vehicle
  • mental stress
  • mechanical vibration
  • multiple mechanisms
  • machinery / equipment
  • noise
  • physical agent
  • physical stress
  • radiation
  • refuse / litter
  • repetitive movement
  • sediment
  • slide or cave-in
  • smoke
  • tools
  • variations in pressure
  • vandalism
  • wind
  • water
  • unspecified mechanisms
  • other

INCIDENT DESCRIPTION

• Description of event (briefly describe what happened

• How / Why did it happen? (briefly describe how / why it happened)

• Immediate Actions?

• Use G-264 to determine risk like hood, consequence, notification and reporting requirements.

RISK LEVEL

• Risk like hood level

• Risk consequence level

• Resultant risk score

REGULATORY AND OTHER NOTIFICATIONS

• Is this a Significant Incident?

  Yes

  No

  N/A

• Identify the highest level of notification required for this incident below.
  Refer G-421 Incident Reporting and investigation procedure.

• Internal (site / project)

• External (media, relatives, other AWX sites)

• Client

• Regulatory Authority

COMMENTS

• Field Staff Member:

• Name (print)

• Signed

  Sign

• Date

  Date

• Client:

• Name (print)

• Signed

  Sign

• Date

  Date

• Resource:

• Name (print)

• Signed

  Sign

• Date

  Date

• Business Development Manager:

• Name (print)

• Signed

  Sign

• Date

  Date

• Business/Division Manager:

• Name (print)

• Signed

  Sign

• Date

  Date

• National Safety Managers Comments:

• Name (print)

• Signed

  Sign

• Date

  Date

CORRECTIVE ACTIONS

• Identify any immediate corrective / preventive actions taken. Identify hierarchy methods used (elimination, substitution, engineering, administration or personal protective equipment)

• Action 1

• Hierarchy method

• Target date

  Date

• Completion date

  Date

• Person responsible

• Action 2

• Hierarchy method

• Target date

  Date

• Completion date

  Date

• Person responsible

• Action 3

• Hierarchy method

• Target date

  Date

• Completion date

  Date

• Person responsible

• Action 4

• Hierarchy method

• Target date

  Date

• Completion date

  Date

• Person responsible