Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Event Type
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The Event is a:
- Hazard
- Near Miss
- Personal Injury
- Environmental
- Equipment
- Non Work Related
- Occupational Exposure
- Occupational Illness/Disease
- Business Process
- External Issue
Event Details
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Brief Description:
Occurred Date/Time
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Select date
Reported Date/Time
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Select date
Responsible Business Unit
Location
Reported by and Company
BHPBIO Responsible Person
Detailed Description
Immediate Actions Taken
Involved and Impacted Items - People
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Persons Name:
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ERMS No:
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Date of Birth:
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Injury Severity:
- No Injury
- Minor Injury No Treatment
- First Aid Case
- Medical Treatment Case
- Restricted Work Case
- Lost Time Case
Roster and Shift
Days and Hours into Roster
Persons Role and Company
Activity being Performed
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Activity being Performed:
- Admin
- Boarding/Exiting
- Equipment
- Bystander
- Catering
- Climbing
- Construction/Building
- Diving
- Dogging/Rigging
- Driving
- Electrical
- Emergency Services
- Gardening
- Housekeeping
- Human Movement
- Inspection/Observing
- Laboratory Activities
- Maintenance
- Manual Handling
- Mining
- Non Work Related Activity
- Not Specified
- Operating Equipment/Machinery
- Passenger
- Servicing
- Surveying Activities
- Towing
Objects Causing Injury
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Object Causing Injury:
- Animal
- Human Agencies
- Flora
- Drugs or Pharmaceutical
- Food and Drink
- Involved only - No Injury or Illness
- Biological Agencies
- Chemicals
- Gas
- Fire/Smoke/Heat
- Fragments
- Non Metallic Substances
- Non Physical Agency
- Radioactive Material
- Weapons
- Environment
- Equipment Non Powered
- Equipment and Tools Powered
- Hand Tools Non Powered
- Office and Household Equipment
- Machinery and Fixed Plant
- Mobile Plant
- Other Transport
- Surface Mobile Equipment
- Vehicle
Mechanism of Injury
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Mechanism of Injury:
- Biological Factors
- Bite - Other Animal
- Bite - Snake
- Bite - Sting Insect
- Effects of Heat/Cold
- Effects of Wind/Weather
- Chemical Substance
- Dismounting/Climbing Down
- Fall from Height
- Trip/Slip
- Involved Only - No Injury or Illness
- Caught between Objects
- Hit by Falling Object
- Hit by Moving Object
- Hit Object with Body Part
- Slide or Cave In
- Confinement in Oxygen Deficient Place
- Drowning or Near Drowning
- Electricity
- Mechanical Vibration
- Pressure Variations
- Radiation
- Rubbing
- Sounds - Long Term
- Sounds - Single Sudden
- Mental Stress Factors
- Muscular Stress
- Repetitive Movement
- Other Multiple Mechanisms
- Vehicle Machinery Accident
Involved and Impacted Items - Environment
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Environment Impacted - Air
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Environment Impacted - Land
- Spill - Hydrocarbon
- Spill - Other
- Disturbance
- Fire
- Erosion
- ARD
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Environment Impacted - Flora
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Environment Impacted - Fauna
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Environment Impacted - Ground Water
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Environment Impacted - Surface Water
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Environment Impacted - Marine
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Environment Impacted - Waste
Environmental Impact Severity
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Impact Severity
- No Effect (involved only)
- Limited Damage/Low Significance
- Minor Short-Term Damage
- Moderate Effects
- Significant Damage
- Severe Damage/Long-Term Effects
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Approximate Cost and Cost Allocated To:
Involved and Impacted Items - Equipment
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Equipment Name:
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Equipment Type:
- Aviation
- Blasting/Explosives
- Building Structure
- Underground Service
- Bulk Storage
- Cleaning/Cooking Equipment
- Communication Equipment
- Diving Equipment
- Electrical Equipment
- Fixed Plant Equipment
- Hygiene Monitoring
- Ionising Radiation Lasers
- Laboratory Equipment
- Maintenance Tools
- Mining Equipment
- Miscellaneous
- Mobile Plant
- Vehicles
- Mobile Plant - Rolling Stock
- Rail Equipment
- Rail Equip - Other than Mobile
- Safety Equipment
- Sea Shipping Equipment
- Ventilation/Air Con Equipment
- Accommodation Facilities
Equipment Impact Severity
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Damage Severity:
- No Damage (involved only)
- A$0-$15K
- A$15K-$150K
- A$150K-$1.5M
- A$1.5M-$15M
- A$15M-$150M
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Mechanism of Damage:
- Not Applicable
- Bogged
- Collision - Forward
- Collision - Reversing
- Corrosion
- Derailment
- Driving over Object
- Dropped Object
- Electrical Failure
- Engulfment
- Exposure to Chemical/Substance
- Fire
- Geotechnical Failure
- Ground Failure
- Hose Failure
- Maintenance Activity Fault
- Mechanical Failure
- Rollover
- Rupture/Split
- Seismic Event
- Skid/Loss of Traction
- Struck by Object
- Submerged
- Tyre Failure
- Weather Event
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Approximate Cost and Cost Allocated To:
Risk Assessment
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Potential Consequence
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Actual Consequence
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Likelihood
Witnesses
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Name and Contact details
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Name and Contact Details
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Name and Contact Details
Investigation Team
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Manager Name:
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Notified of Event
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To Participate in the Investigation:
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HSE Rep Name:
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Notified of Event:
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To Participate in the Investigation:
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Investigation Team Member:
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Investigation Team Member:
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Investigation Team Member:
