FCFA Incident Investigation Report

• Event Title:

• Site

  Select
• Exact location of event
  Address

• Date and Time of Event

  Date

• Date and Time Reported to Management

  Date

• Reported By

• Event Type

  Select Injury / Illness Asset Damage Environmental Impact Near Miss Report Only

  • Injury / Illness
  • Asset Damage
  • Environmental Impact
  • Near Miss
  • Report Only

• Event Classification

  Class 1

  Class 2

  Class 3

• Maximum Reasonable Outcome

  Class 1

  Class 2

  Class 3

• Activity at the time of incident:

  Select Operating mobile plant Operating vehicles / side by sides Picking Fruit Pruning Trees Irrigation works Packing Fruit Other

  • Operating mobile plant
  • Operating vehicles / side by sides
  • Picking Fruit
  • Pruning Trees
  • Irrigation works
  • Packing Fruit
  • Other

• Outline task

  Yes

  No

  N/A

• Brief Description of Event

• Immediate Actions Taken

• Is External Notification Required:

  Yes

  No

• Regulator Notified?

  Yes

  No

• Date and Time Notified

  Date

• Case Number

• Notes

Injury / Illness

• Injured Persons Name

• Employment Status

  Company

  Contractor

  Member of Public

• What is the Organisation's Name

• Injury / Illness Outcome

  Fatality

  Lost Time Incident (LTI)

  Restricted Work Injury

  Medical Treatment Injury (MTI)

  First Aid Injury (FAI)

• How many full working days were lost?

• How many restricted / suitable duty days were there?

• How many restricted /suitable duty days were there?

  Yes

  No

  N/A

• Injury Details

• Injury / Illness Type

  Select Blindness Bruising Burns Concussion Crush Dislocation Fracture - Toes & Fingers Fracture - Major Bones Hernia Internal Injuries Laceration (cuts) Sprains / Strains Other

  • Blindness
  • Bruising
  • Burns
  • Concussion
  • Crush
  • Dislocation
  • Fracture - Toes & Fingers
  • Fracture - Major Bones
  • Hernia
  • Internal Injuries
  • Laceration (cuts)
  • Sprains / Strains
  • Other

• Please specify:

• Injured Body Part

  Select Head Face Eye Ears Nose Mouth Teeth Neck Shoulder Upper Back Lower Back Elbow Forearm Wrist Fingers Thumb

  • Head
  • Face
  • Eye
  • Ears
  • Nose
  • Mouth
  • Teeth
  • Neck
  • Shoulder
  • Upper Back
  • Lower Back
  • Elbow
  • Forearm
  • Wrist
  • Fingers
  • Thumb

• Treatment Details

Asset Damage

• Asset Owner

  Select Company Contractor Member of Public

  • Company
  • Contractor
  • Member of Public

• Asset Type

• Asset Number

• Damage Description

• Operators Name

• Mechanism of Damage

  Traffic Accident

  Vandalism

  Fire

• Estimated cost of Damage

Environmental Impact

• Description of Impact

• Mechanism of Impact

  Atmospheric Contamination

  Land Contamination

  Water Contamination

  Cultural Heritage Impact

  Biodiversity & Biosecurity

• Persons Involved Names

Near Miss

• What was the most likely event outcome:

  Injury / Illness

  Asset Damage

  Environmental Impact

• Type of Investigation

  ICAM

  Basic

• Upload ICAM

  Media

• Question 1

  Yes

  No

  N/A

People

Involved Persons

• Involved Person Name

• Describe the task and condition's leading up to the event

• Describe what happened during the event

• I hereby swear that the above is a true and accurate account of events

• Involved Person Signature

  Sign
Witness Record

• Witness Name

• Describe the task and condition's leading up to the event

• Describe what happend during the event

• I hereby swear that the above is a true and accurate account of events

• Witness Signature

  Sign

Environmental conditions

• What was the conditions like in the lead up and during the event?

  Wet

  Sunny

  Windy

  Calm

  Indoors

• Were there other tasks in the vicinity that may have impacted or influenced the event?

  Yes

  No

• Did the location of the event impact or influence the event?

  Yes

  No

• Please add photos of the scene (close up and distance shots):

  Media

Equiment

• Was equipment involved in the event?

  Yes

  No
Equipment Details

• Was the equipment calibrated / serviced as per OEM requirements?

  Yes

  No

  N/A

• Are maintenance records available?

  Yes

  No

  N/A

• Was a prestart undertaken?

  Yes

  No

  N/A

• Were there any faults identified with the equipment that could have influenced the event?

  Yes

  No

  N/A

• Was the equipment / vehicle / plant being operated appropriately?

  Yes

  No

  N/A

Procedures

• Do Standards / Procedures exist the set the risk tolerance?

  Yes

  No

  N/A

• Was a risk assessment undertaken? Did it identify relevant hazards, risks, & controls?

  Yes

  No

  N/A

• Were SWPs available and being complied with for the task?

  Yes

  No

  N/A

• What were the work instructions provided on the day?

Organisation

• Are inspection records available to verify that work as done is reviewed on a regular basis?

  Yes

  No

  N/A

• Was relevant training provided?

  Yes

  No

  N/A

• Was adequate supervision present?

  Yes

  No

  N/A

Event Timeline

• Date / Time

  Date

• Event

undefined

• Yes

  No

  N/A