BSC Incident Investigation Report V2 - duplicate

• Investigation Title (Insert classification) 1. Injury to worker 2. Plant or equipment damage 3. Near Miss 4. Other

• Insert date and time when injury OCCURRED.

  Date

• Insert date and time when injury was REPORTED.

  Date

• Report document number:

• Name of worker and position (if reported as injury)

• Name of PCBU or individual if incident occurred?

• Contact details of PCBU or individual

• Investigation Officer

• Department / Client (PCBU)

• Department Line Manager

• Team Leader

• Worksite Supervisor

• Primary Contact Name and Details

• Investigation Conducted on:

  Date
• Location
  Address

1. Insert description of incident details

• Task being undertaken at time of incident?

• Description of incident:

• Media

  Media

• Plant and/or property details:

• Third party details:

• Details of injury or damage sustained:

• Add media

  Media
• Location of incident:
  Address

• Corrective Action?<br>1. Immediate<br>2. Within 24 hours<br>3. Further Controls<br>4. Other

  Immediate Attend

  24 Hours

  Further Control

  Other

• Corrective Action?<br>1. Immediate<br>2. Within 24 hours<br>3. Further Controls<br>4. Other

  Immediate Attend

  24 Hours

  Further Control

  Other

• Insert SWMS or SWP applicable details.

Risk and HR Department Notified?

• Risk and HR notified?

  Date

• Name of Risk and HR person notified:

2. Immediate Corrective Action (Short term or no further action required):

• Short term remedial action implemented?

• Tick if short remedial action implemented

• Add media

  Media

• Short term corrective action completed details

  Safe

  At Risk

  N/A

• Rate risk level of short term control: 1 to 5 (Worker at risk) and 5 to 10 (Worker risk minimised to acceptable level). (To be completed in consultation with workers on site and must be to the highest level as is reasonable practicable)

• Name and signature of person responsible for implementing corrective action

  Sign

• Further remedial action required?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

• Comments / Recommendations / Corrective action

• Name and signature of person responsible for following-up on additional actions:

  Sign

3. STATEMENTS: Injured Worker(s) / Supervisor / Team Leader / Witness(s)

1. injured Worker(s) Statement

• Add comments and recommendations

• Media

  Media

• Date and time of interview

  Date

• Injured Worker(s) name and signature

  Sign

• Rate interview 1 Poor level of information and 10 high level of quality information.

2. Supervisor Statement

• Add comments and recommendations

• Media

  Media

• Date and time of interview

  Date

• Supervisor name and signature

  Sign

3. Team Leader Statement

• Add comments and recommendations

• Media

  Media

• Date and time of interview

  Date

• Team leader name and signature

  Sign

4. No: 1. Witness Statement

• Add comments and recommendations

• Media

  Media

• Date and time of interview

  Date

• Witness statement name and signature

  Sign

5. No: 2. Witness Statement

• Add comments and recommendations

• Media

  Media

• Date and time of interview

  Date

• Witness statement name and signature

  Sign

6. No: 3. Witness Statement

• Add comments and recommendations

• Media

  Media

• Date and time of interview

  Date

• Witness statement name and signature

  Sign

7. No 4. Witness Statement

• Add comments and recommendations

• Media

  Media

• Date and time of interview

  Date

• Witness statement name and signature

  Sign

4. Recent site visits and recommendations?

Recommendations?

• Any Recommendations?

  Yes

  No

  Not Applicable

• Media

  Media

• Recommended actions

• Name and signature of person responsible.

  Sign

Controls implemented?

• Implemented?

  Yes

  No

  Not Applicable

• Media

  Media

• Description of controls implemented.

• Name and signature of person responsible.

  Sign

5. Investigation

• 1. Site Description: Prior to and at time of incident

• Photo evidence

  Media

• Sketch Information

  Drawing

• 2. Plant Description: Prior to and at time of incident, for each plant/equipment or vehicle involved.

• Photo evidence

  Media

• Sketch Information

  Drawing

• 3. Person/s involved in incident: Background, experience and evidence of competence.

• Photo evidence

  Media

• Sketch Information

  Drawing

• 4. Other

• Photo evidence

  Media

• Sketch Information

  Drawing

6. Insurance Claims?

• 1. After completing investigation, will an insurance claim be lodged?

  Yes

  No

  Not Applicable

• Comments

• 2. Public liability Insurance?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

• Comments

• 3. Workers Compensation?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

• Comments

• 4. Motor Vehicle?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

• Comments

• 5. Other?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

• Comments

7. Possible Cause of Incident: Factors contributing to the cause of accident?

1. Work Process or Task Factors?

• 1. Inadequate or no risk assessment?

  Safe

  At Risk

  N/A

• 2. Deficient or no SWMS?

  Safe

  At Risk

  N/A

• 3. Worker not following SWMS?

  Safe

  At Risk

  N/A

• 4. Work pressures: Inadequate staff?<br>- Other?

  Safe

  At Risk

  N/A

• 5. Chemicals: No safety data sheet (SDS)

  Safe

  At Risk

  N/A

• 5. Chemicals: Worker not trained in the use if SDS?

  Safe

  At Risk

  N/A

• 6. Inadequate tools or equipment provided for work?

  Safe

  At Risk

  N/A

• 7. Other?

  Safe

  At Risk

  N/A

2. Work Material Factors?

• 1. Equipment failure?

  Safe

  At Risk

  N/A

• 2. Equipment design failure?

  Safe

  At Risk

  N/A

• 3. Faulty or in-serviced equipment?

  Safe

  At Risk

  N/A

• 4. No or inadequate worker induction into site or activity?

  Safe

  At Risk

  N/A

• 5. Lack of correct training?

  Safe

  At Risk

  N/A

• 6. Unsatisfactory supervision?

  Safe

  At Risk

  N/A

• 7. No or inadequate personal protective equipment (PPE)?

  Safe

  At Risk

  N/A

• 8. Other?

  Safe

  At Risk

  N/A

3. Environmental?

• 1. Work area design contributed to incident?

  Safe

  At Risk

  N/A

• 2. Weather conditions? (Wet, slippery, hot, windy etc.)

  Safe

  At Risk

  N/A

• 3. Noise related?<br>- Noise exceeding limits?<br>- High impact noise?

  Safe

  At Risk

  N/A

• 4. Toxic fumes?

  Safe

  At Risk

  N/A

• 5. Poor housekeeping?<br>- Materials laying around?<br>- Work area left un-tidied after use?<br>- Equipment no t stored or secured properly?

  Safe

  At Risk

  N/A

• 6. Other?

  Safe

  At Risk

  N/A

4. Personnel Factors?

• 1. Inadequate or no General WHS Induction into safety systems?

  Safe

  At Risk

  N/A

• 2. Inexperienced?

  Safe

  At Risk

  N/A

• 3. Not assessed for competence?

  Safe

  At Risk

  N/A

• 4. Not trained properly?

  Safe

  At Risk

  N/A

• 5. Health issues contributing to incident?

  Safe

  At Risk

  N/A

• 6. Physical disability: Work expectation unreasonable?<br>- Other?

  Safe

  At Risk

  N/A

• 7. Was fatigue a factor? <br>- What contributed to fatigue?<br>E.g. Workload, social, health?<br>Other?

  Safe

  At Risk

  N/A

• 8. Were safe work procedures followed (If available)?

  Safe

  At Risk

  N/A

• 9. Was the incident due to not following reasonable instruction?

  Safe

  At Risk

  N/A

• 10. Was the worker working in a safe and responsible manner?

  Safe

  At Risk

  N/A

• 11. Other?

  Safe

  At Risk

  N/A

8. Remedial Action and Risk Rating (Please insert details of control introduced and re-rate risk).

• 1. Review of site rules initiated?

  Safe

  At Risk

  N/A

• 2. Site specific risk assessment reviewed?

  Safe

  At Risk

  N/A

• 3. Safe Work Method Statement (SWMS) reviewed? (LIST SWMS NUMBER REVIEWED).

  Safe

  At Risk

  N/A

• 4. Safe Work Procedure (SWP) reviewed?

  Safe

  At Risk

  N/A

• 5. Further training required for worker/s?

  Safe

  At Risk

  N/A

• 6. Worker/s require improved supervision?

  Safe

  At Risk

  N/A

• 7. Plant and equipment inspection and maintenance program to be modified/improved?

  Safe

  At Risk

  N/A

• 8. Workers to improve on housekeeping worksite?

  Safe

  At Risk

  N/A

• 9. Fatigue: Hours of work to be reviewed in relation to type of work?

  Safe

  At Risk

  N/A

• 10. Workers require training on Council health surveillance support program e.g. Social or psychological issues etc?<br>Nominate?

  Safe

  At Risk

  N/A

• 11. Worker employment performance management checked?

  Safe

  At Risk

  N/A

• 12. Activate disciplinary policy and notification to workers?

  Safe

  At Risk

  N/A

• 13. Other

  Safe

  At Risk

  N/A

9. Final Outcomes (No further action required unless circumstance change):

• Type of remedial action implemented?

• Photo evidence

  Media

• Remedial action completed details and risk rating:

  Safe

  At Risk

  N/A

• Name and signature of person responsible for implementing remedial action:

  Sign

• Further remedial action required?

  Select Yes No Not Applicable

  • Yes
  • No
  • Not Applicable

• Further comments, recommendation for remedial action?

• Name and signature of person responsible for following-up on additional actions:

  Sign

• Suggested timeframe for further remedial action? Cost in relation to additional actions?

10. Comments and Recommendations: Supervisor, Team Leader, Investigation Officer, Line Manager.

1. Site Supervisor: Comments and Recommendations

• Comments/Recommendations

• Date and Time

  Date

• Name, title and signature of person conducting compliance audit

  Sign

2. Team Leader: Comments and Recommendations

• Comments/Recommendations

• Date and Time

  Date

• Name, title and signature of person conducting compliance audit

  Sign

3. No: 1 Investigating Officer

• Comments

• Add media

  Media

• Name, title and signature of person conducting compliance audit

  Sign

No: 2. Investigating Officer

• Comments

• Add media

  Media

• Name, title and signature of person conducting compliance audit

  Sign

4. Line Manager: Comments and Recommendations

• Comments/Recommendations

• Date and Time

  Date

• Name, title and signature of person conducting compliance audit

  Sign

11. Workers On-site, Names, Titles and Signature on worksite

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign

• Name of worker and signature (Add title if required)

  Sign