City Of Albany Incident/Hazard Investigation Form

• Incident Number

• Conducted on

  Date

• Prepared by

• Personnel Involved In Investigation

• Synergy Reference Number

Assess the Risk:

• Assess the risk of this incident/accident or hazard.
  Note left of the blue line represents an Insignificant incident/accident or hazard.

  

• The risk assessment rating is:-

• Is this an insignificant incident or accident?

  Yes

  No

  N/A

• Select Bruise Small cut Splinter Minor Property Damage Minor Plant Damage Other

  • Bruise
  • Small cut
  • Splinter
  • Minor Property Damage
  • Minor Plant Damage
  • Other

• Provide details:

Details from incident/accident or hazard form:

• Include a photo of the insignificant incident or accident.

  Media

• Quote the incident/accident or hazard reference number:

• Add media

  Media

• Was the event a hazard?

  Yes

  No

  N/A

• Select Physical Chemical Mechanical Environmental Animal Muscular stress Mental stress Sound & pressure Heat, radiation, electricity

  • Physical
  • Chemical
  • Mechanical
  • Environmental
  • Animal
  • Muscular stress
  • Mental stress
  • Sound & pressure
  • Heat, radiation, electricity

• If this incident/accident is insignificant please go to the end of the investigation form, complete the Conclusion, Summary Actions and sign.
  
  Email completed incident/accident investigation form to Depot Admin Coordinator for processing.

Task being conducted:

• Enter details of task being conducted:

• Include location of incident/accident or hazard
  Address

• Include date and time of incident/accident or hazard

  Date

Persons involved/Witnesses:

• Name/s and Position/s

Reference documentation:

• Enter Details.

Immediate Actions:

• List immediate actions taken as a result of the incident:

Supplementary Actions:

• List supplementary actions taken:

Time line / Sequence of events:

• Enter the sequence of events from initial report and interviews:

• Add photos as required

  Media

• Draw a picture or diagram if this assists with explanation

  Drawing

Contributing Factors: Task / Procedural

• Was a Prestart undertaken?

  Yes

  No

  N/A

• Was a safe work procedure available?

  Yes

  No

  N/A

• Was a safe work procedure used?

  Yes

  No

  N/A

• Was the procedure appropriate?

  Yes

  No

  N/A

• Were appropriate tools and materials available?

  Yes

  No

  N/A

• Was a risk assessment conducted?

  Yes

  No

  N/A

• Were controls in place as per the Risk assessment?

  Yes

  No

  N/A

• Were they used?

  Yes

  No

  N/A

• Personnel were trained to conduct the work?

  Yes

  No

  N/A

• Was a JSA completed noting all hazards?

  Yes

  No

  N/A

• The task remained unchanged from original job?

  Yes

  No

  N/A

• Were change management principals used?

  Yes

  No

  N/A

• Was a Traffic Management Plan in place?

  Yes

  No

  N/A

• Was the site made safe to the public?

  Yes

  No

  N/A

• Was the site made safe to staff prior to work commencing?

  Yes

  No

  N/A

Contributing Factors: Equipment / Substance

• What was the plant number/s of the equipment involved in the hazard/incident?

• Has the Workshop Supervisor been notified of equipment/plant damage?

  Yes

  No

  N/A

• Does the Workshop Supervisor need to be involved in the investigation?

  Yes

  No

  N/A

• All equipment was maintained in good working order?

  Yes

  No

  N/A

• Was the equipment used as designed?

  Yes

  No

  N/A

• Could alternative equipment have been used?

  Yes

  No

  N/A

• Equipment has received scheduled workshop servicing?

  Yes

  No

  N/A

• Were pre-start checks conducted and correct?

  Yes

  No

  N/A

• Personnel were appropriately trained to operate equipment?

  Yes

  No

  N/A

• MSDS are available on site?

  Yes

  No

  N/A

• All labels and signs in place and easy to read?

  Yes

  No

  N/A

• Appropriate PPE is available?

  Yes

  No

  N/A

• PPE was worn correctly?

  Yes

  No

  N/A

Contributing Factors: Environment / Behaviour

• Were weather conditions appropriate to complete the task at the time?

  Yes

  No

  N/A

• Was housekeeping or work area clean, tidy and adequate?

  Yes

  No

  N/A

• Were noise levels at the site low enough not to have been a factor?

  Yes

  No

  N/A

• Was lighting adequate?

  Yes

  No

  N/A

• Were you alert and not suffering from fatigue?

  Yes

  No

  N/A

• Did you have enough time to complete the job or task?

  Yes

  No

  N/A

• Were you paying full attention to the task?

  Yes

  No

  N/A

• If you are required to wear visual aids were you wearing them?

  Yes

  No

  N/A

• Were workers adequately supervised?

  Yes

  No

  N/A

• Were workers experienced to perform the task?

  Yes

  No

  N/A

Other Contributing factors:

• List any other contributing factors:

• Add photos as required

  Media

Conclusions:

• Review the Contributing Factors Sections and analyse any Red "NO" responses to conclude. The investigation revealed:-

• Include additional photos if required

  Media

Recommendations:

• Use the Hierarchy of Controls to assist with recommendations, solutions, actions or controls

• Eliminated? Eg. Discontinued use of product, equipment, ceased work process

  Yes

  No

  N/A

• Actions to be taken

• By Whom

• By When

  Date

• Substituted? Eg. Replaced with similar item that does the same job but with a lower hazard level

  Yes

  No

  N/A

• Actions to be taken

• By Whom

• By When

  Date

• Isolated? Eg. Put barriers between the person and the hazard

  Yes

  No

  N/A

• Actions to be taken

• By Whom

• By When

  Date

• Engineered? Eg. Change the process, equipment or tools so the risk is reduced

  Yes

  No

  N/A

• Actions to be taken

• By Whom

• By When

  Date

• Administered? Eg. Are there guidelines, procedures, rosters, training etc in place to minimise the risk

  Yes

  No

  N/A

• Actions to be taken

• By Whom

• By When

  Date

• PPE? Eg. Was equipment worn to provide a temporary barrier

  Yes

  No

  N/A

• Actions to be taken

• By Whom

• By When

  Date

• By When

  Date

• Summary of Actions:

• Include additional photos if required.

  Media

• Signature of investigating officer:

  Sign

• Signature of manager:

  Sign

• Signature of OHS Representative

  Sign