Environmental Investigation Record (5 whys)

• Incident Report Number#

Event Notification and Investigation Record

• It is a requirement of this site that all incidents and accidents no matter how minor are reported to the ############ or delegate immediately upon the incident occurring. This is to ensure that the area can be made secure if an investigation into the incident is required. Under no circumstances is a worker to enter or continue work in an area where an incident has occurred.

• It is the responsibility of the ############ or delegate to determine if the site requires to be secured for the purposes of investigation.

• Below is a flow diagram of the reporting and investigation process:

Location of Incident

• Location

  a

Event Title

• Enter Event Title:

Report Entered by:

• Name:

PART 1 – Notification - Event details, must be completed for ALL event reports) Refer to the attached incident notification flow chart.

• Event Date & Time:

  Date

• Event Reported Date & Time:

  Date

• Event Reported to:

• Witness Name/s:

• Event Description:

• Sketch event scene or picture of sequence of events, including locations of involved persons, equipment at the time of the event. Measure distances – use surveyors for serious events i.e. rollovers. Take photographs (attach in First Priority)

• Event Diagram:

  Media

• Exact Event Location:

• Event Type: Select the appropriate Event Type and complete the information within.

• Was drug and alcohol testing conducted / required?

  Yes

  No

  N/A

• Provide details:

• Was there a delay in reporting to either internal or external personnel

  Yes

  No

  N/A

• Provide details:

• Was a supplier or contractor involved in the incident?

  Yes

  No

  N/A

• Provide details:

Event Type: Environmental

• Was the event an Environmental incident?

  Yes

  No

  N/A

• If yes, what type of environmental event:

  Yes

  No

  N/A

• Select the applicable category:

  Select ENV - Nuisance (noise / dust) ENV - Water pollution / contamination ENV - Ground disturbance ENV - Flora / Fauna ENV - Cultural / Heritage ENV - Fire ENV - Customer complaint ENV - Blasting ENV - Chemical release ENV - Acid Sulphate Soils ENV - Waste / rubbish

  • ENV - Nuisance (noise / dust)
  • ENV - Water pollution / contamination
  • ENV - Ground disturbance
  • ENV - Flora / Fauna
  • ENV - Cultural / Heritage
  • ENV - Fire
  • ENV - Customer complaint
  • ENV - Blasting
  • ENV - Chemical release
  • ENV - Acid Sulphate Soils
  • ENV - Waste / rubbish

• Depending on Environmental Category Selected, complete the below corresponding sections:

A. Spill Details

• Was there a spill event?

  Yes

  No

  N/A

• Answer the below questions:

• Spilled Material

• Quantity Spilled (L):

• Area affected (m2):

• Quantity spilled (L):

• Total Response time:

• Surface type:

• Did the spill go into a waterway or drain? If yes contact the SSE & RCO immediately.

  Yes

  No

  N/A

• What is the toxicity of the chemical released?

• If not known, what is the flow / destruction rate?

• Was a spill response kit used?

  Yes

  No

  N/A

• Type & quantity of the kit used (i.e. 10kg absorbent material, socks etc.)

• Was the contaminated waste placed into disposal bags?

  Yes

  No

  N/A

• Is the SDS for the chemical attached?

  Yes

  No

  N/A

• Is there any acid sulphate soil disturbance?

  Yes

  No

  N/A

• If yes, please provide further details:

B. Fire Details:

• Was there a fire incident?

  Yes

  No

  N/A

• If yes, complete the below questions:

• What is the duration of the fire?

• Has the fire ceased?

• What is the scope / area of damage?

C. Nuisance (dust / noise) Details:

• Was there a nuisance (dust / noise) incident?

  Yes

  No

  N/A

• If yes, complete the below questions:

• What is the environmental nuisance (dust or noise)?

• What is the duration of the nuisance?

• What is the scope / area of the damage?

• Wind direction and speed?

D. Flora / Fauna Details:

• Was there a flora / fauna incident?

  Yes

  No

  N/A

• If yes, complete the below questions:

• What is the extent of the flora / fauna damage sustained?

• Location of incident:

• Description of flora / fauna (include photos):

E. Cultural / Heritage Details:

• Was there a cultural / heritage incident?

  Yes

  No

  N/A

• If yes, complete the below questions

• Was any cultural or heritage items / artefacts damaged?

  Yes

  No

  N/A

• Location of incident:

• Description of the extent of damage (include photos):

F. Waste / Rubbish Details:

• Was there a waste / rubbish incident?

  Yes

  No

  N/A

• If yes, complete the below questions:

• What is the scope / area of the incorrectly disposed of waste / rubbish?

• Is the waste hazardous?

  Yes

  No

  N/A

• Location of incident:

• Description of waste / rubbish (include photos):

G. Blasting / Ground Disturbance Details:

• Was there a blasting / ground disturbance incident?

  Yes

  No

  N/A

• If yes, complete the below questions:

• What is the nature of the incident?

• Is blasting within the designated times as per the requirements of the EA for this site?

  Yes

  No

  N/A

• Location of incident:

• What is the scope / area of damage?

H. Customer Complaint Details:

• Was the incident a result of a customer complaint?

  Yes

  No

  N/A

• If yes complete the below questions:

• Describe the nature of the complaint?

• Is the complaint from a Customer or Local Resident?

  Yes

  No

  N/A

• If yes, provide details:

I. Reportable Incident Details:

• Is the incident reportable as per the environmental protection legislative requirements?

  Yes

  No

  N/A

• If yes, provide details (i.e. person contacted at DES, report etc.)

PART 2 - Cost

• Are there any costs associated with this incident?

  Yes

  No

  N/A

• If yes, please complete the below:

Environmental Impact

• Area of Environmental Impact

• Estimated Cost:

Involved Equipment

• Equipment Name / Type:

• Estimated Cost:

Involved Business Process

• Process Name / Type:

• Description:

• Estimated Cost:

Total Cost (Environmental + Equipment + Business Process)

• Estimated Total Cost:

PART 3 – Consequence Risk Ranking - includes immediate corrective actions & initial sign off

• Refer to table for Consequence Risk Ranking:

• Actual Event Level

  Level 1

  Level 2

  Level 3

  Level 4

  Level 5

• Potential Event Level

  Level 1

  Level 2

  Level 3

  Level 4

  Level 5

Contributing Factors (Basic investigation only - 5 WHYS)

• Were there any Behavioural Causes? If yes, select all that apply below:

  Yes

  No

  N/A

• Fatigued?

• Procedure / Specification not appropriate?

• Procedure / Specification not completed?

• Procedure / Specification not followed?

• Risk assessment / JSEA / SLAM not appropriate?

• Risk assessment / JSEA / SLAM not completed?

• Stresses?

• Supervision not adequate?

• Task design not appropriate?

• Time pressure?

• Training insufficient?

• Unauthorised behaviour?

• Unprofessional behaviour?

• Working after hours?

• Working alone?

• Equipment not used correctly?

• Other, describe?

• Add additional information for each checked box?

• Physical Causes. If yes, select all that apply below:

  Yes

  No

  N/A

• Equipment malfuctioning?

• Equipment not appropriate?

• Flooring?

• Safety equipment malfunctioning?

• Safety equipment not appropriate?

• Safety equipment not used?

• Weather?

• Workplace design not appropriate?

• Workplace poorly maintained?

• Uncategorised cause?

• Other, describe?

• Add additional information for each checked box:

PART 4 - ICAM Process

• For all Actual Level 1 & 2 events, Parts 1, 2, 3, & 5 are to be completed.

• For all Actual Level 3 events and greater, Parts 1, 2, 3, 4 & 5 MUST be completed.

• Refer to the ICAM - Incident Investigation Reference Guide for assistance (located on SharePoint)

• Is a full ICAM required for this incident

  Yes

  No

  N/A

• If yes, complete investigation using Environmental Investigation Record (ICAM) form.

Immediate, Correct or Preventative Actions

• Guidelines for Raising Corrective Actions

• The investigation should identify recommendations for corrective actions to prevent recurrence, reduce risk and advance safety. This can best be achieved by addressing all absent or failed defences and organisational factors identified by the ICAM analysis. Not all contributing factors can be completely eliminated, and some may be eliminated only at a prohibitive cost. The investigation team should work with line management in the development of corrective actions.
  
  Recommendations must have a direct link back to the incident and must target: Prevention of recurrence and Reduction of risk. Recommendation must address each Absent or failed defences and Organisational Factor.
  
  The corrective actions recommended by the investigation team should be SMARTER (Specific, Measurable, Accountable, Reasonable, Timely, Effective, Reviewed).
  
  

• Each recommendation is a written statement of the action management should take to correct a contributing factor. The team reviews each contributing factor and:
  
  • Formulates recommendations which, if implemented, will reduce the likelihood of that factor contributing to future incidents;
  • Recommends improvement to the system defences to limit the consequences of the contributing factor, so that residual risk is recognised by management as acceptable;
  • Makes interim recommendations for immediate corrective actions after an incident or near-miss as a short-term measure to mitigate current risks prior to the establishment of long-term
  corrective actions.
  
  It is essential any corrective action be fully evaluated by Management to ensure change/s do not weaken other defences or expose other risks. A recommendation must address an organisational or systemic deficiency; it should not be a one-time or band-aid fix.
  
  Recommendations should be based upon the Hierarchy of Control (refer to the Risk Management Procedure for further information).
  
  Each recommendation is numbered individually to ensure and simplify action assignment and completion control. The investigation should cross reference their recommendations to the identified absent / failed defences and organisational factors to ensure they have all been addressed.
  

Immediate, Corrective or Preventative Actions

• Include person responsible and due date:

• Action 1:

• Action 2:

• Action 3:

• Action 4:

• Action 5:

• Action 6:

• Action 7:

• Action 8:

• Action 9:

• Action 10:

PART 5 - Sign-off

Initial Sign-off

• The EVENT OWNER (e.g. Shift Supervisor) should sign to indicate that they have reviewed and accepted the report, including the actions and priorities. Any relevant comments can be added if required.
  
  The INVOLVED PERSON or EMPLOYEE SAFETY REPRESENTATIVE should sign to indicate that they have reviewed and accepted the report, including the actions and priorities. Any relevant comments can be added if required.
  
  The ############### or DELEGATE should sign to indicate that they have reviewed and accepted the report, including the actions and priorities. Any relevant comments can be added if required.
  
  The ############ should sign to indicate that they have reviewed and accepted the report, including the actions and priorities, and enter any relevant comments.
  
  The ############ should sign to indicate that they have reviewed and accepted the report, including the actions and priorities. Any relevant comments can be added if required. ########## sign-off is only required for events with an Actual Risk Ranking of Level 3 or greater.
  
  FINAL SIGN OFF – is only completed once reviewed by the ########### to ensure verification of actions have been implemented and closed off before closing this investigation officially.
  
  

Supervisor Acceptance and Comments

• Name:

• Signature:

  Sign

• Date & Time:

  Date

• Comments:

Involved Person Acceptance and Comments

• Name:

• Signature:

  Sign

• Date & Time:

  Date

• Comments:

########## Acceptance and Comments

• Name:

• Signature:

  Sign

• Date:(dd/mm/yy)

  Date

• Comments:

########### Acceptance and Comments

• Name:

• Signature:

  Sign

• Date:(dd/mm/yy)

  Date

• Statutory Reporting Requirements:

  Yes

  No

  N/A

• Completed:

  Yes

  No

  N/A

• Corrective Actions Required:

  Yes

  No

  N/A

• Completed:

  Yes

  No

  N/A

• Communication to personnel (specify medium and date (i.e. safety meeting, TBT, audit, KPI's, other))

• Review Date:

  Yes

  No

  N/A

• Comments:

  Yes

  No

  N/A

############# Acceptance and Comments

• Only required for Actual Level 3 risk ranking and above

• Name:

• Signature:

  Sign

• Date & Time:

  Date

• Comments

Final Sign Off (actions have been completed and verified by ##########)

• Name:

• Signature:

  Sign

• Date & Time:

  Date

• Comments: