Incident, Accident, Near Miss Report

• Date

  Date

• Reported completed by

• Permit to Work Number

• Site / location

Occurrence Details

• Date & Time of Injury, Accident or Near Miss

  Date

• Area / Location of site where Injury, Accident or Near Miss Happened (e.g. track, tower)

• Was this an Incident, Accident, Near Miss or Property Damage event?

  Select Incident Accident Property Damage Near Miss

  • Incident
  • Accident
  • Property Damage
  • Near Miss

• An Incident is an event that has unintentionally happened, but may not have resulted in damage, harm or injury.

• Type of injury

  Select Crush / Impact Strain / Sprain Fracture / Break Cut / Laceration Dislocation Foreign Body Penetration Bruising Scratch / Abrasion Amputation Burn / Scald Internal Injury Allergic Reaction No injury sustained Other

  • Crush / Impact
  • Strain / Sprain
  • Fracture / Break
  • Cut / Laceration
  • Dislocation
  • Foreign Body
  • Penetration
  • Bruising
  • Scratch / Abrasion
  • Amputation
  • Burn / Scald
  • Internal Injury
  • Allergic Reaction
  • No injury sustained
  • Other

• Type of injury

• Describe body part affected and the nature of the injury

• Injury Severity

  Minor

  Moderate

  Serious

• Injury Response

  NIL

  First Aid only

  Medical attention

  Emergency Services

  Death

• Has any damage occurred?

  Yes

  No

• Describe the property / item / material damaged

• Describe the nature of the damage

• Severity of damage

  Minor

  Moderate

  Serious

• Describe the property / item / material damaged

• Describe the nature of the damage

• Severity of property damage

  Minor

  Moderate

  Serious

• A near miss is an incident that occurred that did not lead to damage, harm or injury.

• Describe the near miss ocurrence

• Describe potential injury or harm

• Describe potential damage

• Severity of near miss

  Minor

  Moderate

  Serious

• An accident is an event that has unintentionally happened, that resulted in damage, injury or harm.

• Type of injury

  Select Crush / Impact Strain / Sprain Fracture / Break Cut / Laceration Dislocation Foreign Body Penetration Bruising Scratch / Abrasion Amputation Burn / Scald Internal Injury Allergic Reaction No injury sustained Other

  • Crush / Impact
  • Strain / Sprain
  • Fracture / Break
  • Cut / Laceration
  • Dislocation
  • Foreign Body
  • Penetration
  • Bruising
  • Scratch / Abrasion
  • Amputation
  • Burn / Scald
  • Internal Injury
  • Allergic Reaction
  • No injury sustained
  • Other

• Type of injury

• Describe body part affected and the nature of the injury

• Injury Severity

  Minor

  Moderate

  Serious

• Injury Response

  NIL

  First Aid only

  Medical attention

  Emergency Services

  Death

• Has any damage occurred?

  Yes

  No

• Describe the property / item / material damaged

• Describe the nature of the damage

• Severity of damage

  Minor

  Moderate

  Serious

• Did anyone get injured?

  Yes

  No
Injured team member/s information

• Full name

• Category

  Select Full time Part time Contractor Visitor

  • Full time
  • Part time
  • Contractor
  • Visitor

• Length of time working for Tetro Group

  less than 1 month

  > 1 to 6 months

  > 6 months to 1 year

  1 year to 5 years

  > 5 years

• Has the team member performed this task in the past?

  Yes

  No

Event Description

• Describe prior events leading up to the event

• Describe what happened in detailed steps

• What were the contributing causes (these are the actions or inaction or conditions at the time that triggered the event)

• What were the primary causes (these are the system or process failures, planning and / or management failures that allowed the potential for the event to develop in the first place)

• Were there any witnesses to the event?

  Yes

  No

  N/A

• First and Last Names of Witnesses

• Was PPE required for this task?

  Yes

  No

• What PPE was required for this job?

  Select Long sleeve high vis shirt Long pants Helmet Safety Boots Gloves Ear protection Eye protection Harness RF Monitor Respiratory mask Wet weather high vis gear Other

  • Long sleeve high vis shirt
  • Long pants
  • Helmet
  • Safety Boots
  • Gloves
  • Ear protection
  • Eye protection
  • Harness
  • RF Monitor
  • Respiratory mask
  • Wet weather high vis gear
  • Other

• Was a the PPE required above, used during this job?

  Yes

  No

• With what reasoning?

• Other PPE requirement

• Has the harness been certified to AS/NZS 1891.1.2007

  Yes

  No

• Could anything have been done different to prevent the event?

  Yes

  No

• What could you have done differently?

• Was training provided for this task?

  Yes

  No

  N/A

• What training?

• Were any safety controls by-passed?

  Yes

  No

• Please explain what safety controls you by-passed

• After your involvement with this reported event, is there any insight which could be shared or future preventative action recommendations?

  Yes

  No

• Please share insights

Pictures

• Take pictures of injury/accident including body part(s), location, equipment, tools, etc.

  Media

• Report completed by

  Sign