BSC Incident / Investigation Report v:0.3 - Live

• Investigation title

undefined

• Prepared by

• Investigation date

  Date

• Brief description of works

• Incident notification form title and number

• Partial entry of details from hazard incident notification form.

• Multiple parties involved (Provide detail)

  Yes

  No

  Pending further investigation

  N/a
Council Details

• Council Division

• Council Section

• Manager

• Mobile

• Team Leader / Coordinator

• Mobile

• Supervisor

• Mobile

PCBU Details (if required)

• Company

• Office phone

• Manager

• Mobile

• Production Manager

• Mobile

• Worksite Manager

• Mobile

• Date reported to People and Culture/WHS Advisor/Coordinator

  Date

• SafeWork NSW Notified (Comments in notes)

  Yes

  No

  Pending further investigation

  N/a

• SafeWork Ref No:

Incident Details

• Date and Time of Incident

  Date
• Location of Incident
  Address

• Incident Severity?

  Work stopped

  High

  Medium

  Low

  Minor

• Incident type and provide any detail in notes

  Select Injury Plant Damage Near-Miss Property Damage Reportable / Notifiable Safety Breach Other

  • Injury
  • Plant Damage
  • Near-Miss
  • Property Damage
  • Reportable / Notifiable
  • Safety Breach
  • Other

• Plant type

• Plant identification number

• Name of on-duty supervisor at time of incident?

• Was medical attention administered?

  Yes

  No

  N/a

• What kind of medical attention was administered?

  Select Doctor Consulted First Aid Ambulance Hospital Other

  • Doctor Consulted
  • First Aid
  • Ambulance
  • Hospital
  • Other

• Please detail medical attention

Incident Summary

• Describe what happened. Please be detailed but state facts only (Add in notes)

• Do you wish to include a timeline of events for this incident?

  Yes

  No

  Pending further investigation

  N/a

Incident Timeline

• Build a timeline of key incident events below

Event

• Event Date / Time

  Date

• Event Description

• Photo

  Media

• What were the weather / environmental conditions at the time of the incident?

  Select Hot Dusty Clear Cloudy Rain Windy Haze Other

  • Hot
  • Dusty
  • Clear
  • Cloudy
  • Rain
  • Windy
  • Haze
  • Other

• Describe the weather / environmental conditions at the time of the incident

• Select

  Document

  Photos

  Other

Evidence and Attachments (Equipment and/or Plant)

• Which of the following do you need to attach to this report to accuractly document this incident?

  Select Equipment Details Vehicle Details Public Damages Other Items

  • Equipment Details
  • Vehicle Details
  • Public Damages
  • Other Items

Evidence Log

• Please log all relevant evidence below

Evidence

• Evidence Description

• Evidence ID number (if applicable)

• Type of evidence

  Document

  Photos

  Other

• Photos of evidence (if applicable)

  Media

• Please detail any further information regarding this evidence (if applicable)

Vehicle Log

• Please log all relevant vehicle details below

Vehicle

• Vehicle Make

• Vehicle Model

• Vehicle Registration

• Driver (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this vehicle (if applicable)

Damage Log

• Please log all relevant damage details below

Damage

• Damage description

• ID number (if applicable)

• Photos of damage (if applicable)

  Media

• Please detail any further information regarding this damage (if applicable)

Other Items Log

• Please log all relevant details of other items below

Item

• Item description

• ID number (if applicable)

• Photos of item (if applicable)

  Media

• Please detail any further information regarding this item (if applicable)

Equipment Log

• Please log all relevant equipment details below

Equipment

• Equipment Make

• Equipment Model

• Equipment ID number (if applicable)

• Photos of equipment (if applicable)

  Media

• Please detail any further information regarding this equipment (if applicable)

People involved

• Please document all people involved in this incident

Person

• Full Name

• Role

• Contact phone number

• Photo

  Media

• What is this person's relation to the incident? (select all that apply)

  Select Reporter of incident Injured person Witness Primary person involved Secondary Involvement On-duty supervisor Investigator Other

  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Other

• Describe this person's relation to the incident

• Description of person's involvement with the incident, including all relevant information required (Add in notes)?

  Yes

  No

  Pending further investigation

  N/a

• Attach any relevant photos regarding this person

• Do you want to log a statement for this person? (Add statement in notes)

  Yes

  No

  Pending further investigation

  N/a

• Person Signature

  Sign

• Date & Time of Statement

  Date

• Has this person sustained an injury?

  Yes

  No

Injury Details

• Type of injury or illness? (select all that apply)

  Select Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & Spinal Cord Amputation Other

  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & Spinal Cord
  • Amputation
  • Other

• Describe type of injury or illness

• Parts of body affected? (select all that apply)

  Select General Ailment Head Eye (Right) Eye (Left) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Right) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • General Ailment
  • Head
  • Eye (Right)
  • Eye (Left)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Right)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• Please describe injury location

• Describe this injury or illness

• What was the cause of this injury or illness?

Root Cause Analysis / Contributing Factors (Investigator)

• What were the contributing factors to this incident occurring? (select all that apply)

  Select Equipment Defects Unauthorized Equipment Use Improper Equipment Use Lack of protective safety devices Employee operating at inappropriate speed Equipment used outside rated capacity Lack of PPE Inappropriate PPE Untidy Conditions (Poor Housekeeping) Safety procedures not followed Inadequate ventilation Drugs or Alcohol

  • Equipment Defects
  • Unauthorized Equipment Use
  • Improper Equipment Use
  • Lack of protective safety devices
  • Employee operating at inappropriate speed
  • Equipment used outside rated capacity
  • Lack of PPE
  • Inappropriate PPE
  • Untidy Conditions (Poor Housekeeping)
  • Safety procedures not followed
  • Inadequate ventilation
  • Drugs or Alcohol

• A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident.

• Has the root cause of this issue been able to be identified?

  Yes

  No

  Pending further investigation

  N/a

• Why is the root cause for this issue unable to be identified at this time?

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

• What is the root cause of this incident? Please consider and include all contributing factors

• Has the root cause of this issue been rectified or eliminated?

  Yes

  No

  N/a

• How was the root cause rectified or eliminated?

• Please attach any relevant photos or media

  Media

• Please provide any relevant further details

• How likely is this incident to reoccur in future?

  Select Certain Very Likely Likely Unlikely Very Unlikely Never Unclear / Not Determinable

  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

Corrective Actions and sign off (Investigator recommended actions and assignment of responsible person)

• Are corrective/further actions required with regard to this incident?

  Yes

  No

  Pending further investigation

  N/a

• Persons assigned to address actions or recommendations (Insert name)

• Further comments (Add in notes)

  Yes

  No

  Pending further investigation

  N/a

• Name/title and signature of lead investigator

  Sign

• Lead investigator further comments (If required)

• Name/title and signature of supporting investigator(s)

  Sign

• Support investigator comments (If required)

  Sign