Downer Accident Investigation - UFB

• Document No. UFB

• Accident investigation loss control template

• Client (select from drop box)

  Downer

  Chorus

  Vodafone

• Program I.e. UFB, RBI, UFB schools, BAU

  UFB

  RBI

  UFB schools

  Business As Usual

• Date of the incident

  Date

• Date reported

  Date

• Prepared by

• Location of incident
  Address

• Name of persons or contractor involved

• Employee/contractor/other(Select)

  Select Downer employee customer employee contractor employee member of public non-applicable

  • Downer employee
  • customer employee
  • contractor employee
  • member of public
  • non-applicable

• Type of incident

  Select lost time injury medical treatment first aid injury plant damage service safety critical strike serious harm environmental incident cardinal rule breach

  • lost time injury
  • medical treatment
  • first aid injury
  • plant damage
  • service safety critical strike
  • serious harm
  • environmental incident
  • cardinal rule breach

• Legal requirements:
  
  Notify the Zero Harm Advisor immediately as per Downer policy
  Do not remove items from the scene.
  Do not interfere with the scene unless safety critical
  Freeze and make scene safe, the scene is not to be disturbed under the requirements of the Health and Safety in Employment act 1992, and HSE Amendments Act 2002 unto. Approval has been obtained by a zero harm advisor for WorkSAFE nz.
  

• Serious harm notification has been completed by phone, and hard copy provided to WorkSAFE nz (Former DoL).

  Yes

  No

  N/A

• Record vehicle plant damage information I.e. Rego, wof, include damage images in this report.

• Ensure INF form is completed by the ZHA to senior management

• Ensure INX number entered by the ZHA and INF submitted to senior ZH management - ZHA responsibility.

• Ensure Zero Harm Advisor notified
  Ensure the National Environmental and Sustainability Manager is notified
  Ensure ESRM01 completed.

• Select Cardinal Rule Applicable

  Select standing in path of mobile plant and machinery working at heights without controls confined space entry without permission standing under suspended loads isolation zones tampering with safety mechanisms unauthorised work on plant and equipment lock out tag out not present mobile phones or seatbelts Drugs an or alcohol, or impairing substances

  • standing in path of mobile plant and machinery
  • working at heights without controls
  • confined space entry without permission
  • standing under suspended loads
  • isolation zones
  • tampering with safety mechanisms
  • unauthorised work on plant and equipment
  • lock out tag out not present
  • mobile phones or seatbelts
  • Drugs an or alcohol, or impairing substances

• ZERO HARM ADVISOR must be notified immediately!
  ICAM Investigation must be undertaken
  Considered high potential by default

• Which parts of the body have been injured and describe extent of injury(s)

• Describe the damage to the plant service and or equipment where possible.

• Was a Drug and Alcohol test performed?

  Yes

  No

• Results must be sent to the Zero Harm Advisor by NZDDA 0508 (DRUG TEST)
  Downer policy permits ;
  - Post incident, and
  - Just cause testing.
  
  Refusal to submit for a drug and alcohol text on these grounds may result removal fro. Site pending further investigation may result in dismissal.
  Test results must be provided to the individual and the zero harm team. Results must not be kept by any other person.

• Record relevant images

  Media

• Any relevant drawings

  Drawing

• Actions taken

  Select nil first aid treatment doctor hospital environmental controls under investigation

  • nil
  • first aid treatment
  • doctor
  • hospital
  • environmental controls
  • under investigation

Accident statements

• Described what happened?

• Witness statements

• Name and contact details of people involved

• Cost centre (select)

  Select 10.222 national office UFB 10.223 LNI UFB 10.224 WTN UFB 10.225 SI UFB 10.037 QA 10.014 ZH

  • 10.222 national office UFB
  • 10.223 LNI UFB
  • 10.224 WTN UFB
  • 10.225 SI UFB
  • 10.037 QA
  • 10.014 ZH

• Select persons to be notified

  Select Michael Maunsell Jason Spencer Jason Stapp Chris Ely Al Christ

  • Michael Maunsell
  • Jason Spencer
  • Jason Stapp
  • Chris Ely
  • Al Christ

• Select persons to be notified

  Select Michael Curran Sam Staples Melanie Schroder Jim Goodall Athol Nelson Pete Sims

  • Michael Curran
  • Sam Staples
  • Melanie Schroder
  • Jim Goodall
  • Athol Nelson
  • Pete Sims

• Select persons to be notified

  Select Steve Tobin Michael Walding Stephen Allan Nathan Gordon Kevin McMullan Mata Taramai Sean Gifford

  • Steve Tobin
  • Michael Walding
  • Stephen Allan
  • Nathan Gordon
  • Kevin McMullan
  • Mata Taramai
  • Sean Gifford

• Select persons to be notified

  Select Robert Jugovac John Bartlett Marthinus Esteryse

  • Robert Jugovac
  • John Bartlett
  • Marthinus Esteryse

• Select persons to be notified

  Select Sam Astwood-Maddren Grant Jackson Peter Gordon

  • Sam Astwood-Maddren
  • Grant Jackson
  • Peter Gordon

• Select persons to be notified

  Select Jason Stapp Michael Purdie-Smith Kevin Lockley Shannon Wright Bruce Lambie

  • Jason Stapp
  • Michael Purdie-Smith
  • Kevin Lockley
  • Shannon Wright
  • Bruce Lambie

• Hazards identified

  Select physical chemical biological socio psycholigical other

  • physical
  • chemical
  • biological
  • socio psycholigical
  • other

• Select

  Select slip trip fall electrical contact struck by moving object service strike trenching technology trenchless technology manual digging confined spaces working at heights trenches and excavations

  • slip trip fall
  • electrical contact
  • struck by moving object
  • service strike
  • trenching technology
  • trenchless technology
  • manual digging
  • confined spaces
  • working at heights
  • trenches and excavations

• Select

  Select skin contact inhalation ingestion contamination loss of sediment control spill to environment

  • skin contact
  • inhalation
  • ingestion
  • contamination
  • loss of sediment control
  • spill to environment

• Select

  Select waste contaminated waste sewage animal

  • waste
  • contaminated waste
  • sewage
  • animal

• Select

  Select fatigue drugs and alcohol time constraints

  • fatigue
  • drugs and alcohol
  • time constraints

• Provide details

Corrective and preventative actions

• Outline the corrective actions taken in response to this incident.

• Name of person filing report and signature

  Sign

• Regional management group I.e. LNI, WTN, SI, NATNL

  Select 10.222 national office UFB 10.223 LNI UFB 10.224 WTN UFB 10.225 SI UFB 10.037 QA 10.014 ZH

  • 10.222 national office UFB
  • 10.223 LNI UFB
  • 10.224 WTN UFB
  • 10.225 SI UFB
  • 10.037 QA
  • 10.014 ZH

• Select manager for notification and actions

  Select Michael Maunsell Jason Spencer Jason Stapp Chris Ely Al Christ

  • Michael Maunsell
  • Jason Spencer
  • Jason Stapp
  • Chris Ely
  • Al Christ

• Select manager for notification and actions

  Select Michael Curran Sam Staples Melanie Schroder Jim Goodall Athol Nelson Pete Sims

  • Michael Curran
  • Sam Staples
  • Melanie Schroder
  • Jim Goodall
  • Athol Nelson
  • Pete Sims

• Select manager for notification and actions

  Select Steve Tobin Michael Walding Stephen Allan Nathan Gordon Kevin McMullan Mata Taramai Sean Gifford

  • Steve Tobin
  • Michael Walding
  • Stephen Allan
  • Nathan Gordon
  • Kevin McMullan
  • Mata Taramai
  • Sean Gifford

• Select manager for notification and actions

  Select Robert Jugovac John Bartlett Marthinus Esteryse

  • Robert Jugovac
  • John Bartlett
  • Marthinus Esteryse

• Responsibilities:
  
  Management are to ensure the actions identified in the report are closed out in proper timeliness as per the requirements of SPM 18 and the Downer EDI Engineering accident investigation procedure and policy.
  Actions should signed off by management with completion dates noted.
  Records of activities are subject to auditing in accordance with Downer 4801 Safety Management Systems requirements.