Incident Investigation Ver1.1

• Audit Title

• Document No.

Incident Details

• Incident Category

  Select Lost Time Injury Medical Treatment Injury First Aid Injury Near Miss Vehicle/Plant/Equipment Damage Vehicle Accident Property Damage Service Damage

  • Lost Time Injury
  • Medical Treatment Injury
  • First Aid Injury
  • Near Miss
  • Vehicle/Plant/Equipment Damage
  • Vehicle Accident
  • Property Damage
  • Service Damage

• Date and Time of Incident

  Date
• Location of Incident
  Address

• Details of incident

• Photos of Incident

  Media

• Personnel onsite

  Select Tye Anslow Steven Benjimen Stevan Burkin Levi Cable Simon Calderbank Phil Celcer David Coleman Peter Cook Andrew Crane Chris Davies Simon Davies Kertas Elliott John Fox Damian Gleed Peter Harriman Dean Hollwarth Darren Hort Brian Humberstone Steve Jones Gareth Lane Michael Lett Daniel Logan Troy Luxton Chris Mculloch Francis McNaughton Jason McNee Adam Merriman Adrian Moore Karl Nuske Tommy Prentice Michael Quake Damian Rees Brad Saggers Tim Schubert Mitch Sumpton Michael Teale Drew Thompson Graham Tooke Matt Treasure Louis Williams Michael Wilson Alan Brown Lee Brown Craig Busquets David Clements Reg Day Lewis Harriman Rob Jurjevich Pat Middle Trent Proctor Dave Proctor Kara Clements Paul Clements

  • Tye Anslow
  • Steven Benjimen
  • Stevan Burkin
  • Levi Cable
  • Simon Calderbank
  • Phil Celcer
  • David Coleman
  • Peter Cook
  • Andrew Crane
  • Chris Davies
  • Simon Davies
  • Kertas Elliott
  • John Fox
  • Damian Gleed
  • Peter Harriman
  • Dean Hollwarth
  • Darren Hort
  • Brian Humberstone
  • Steve Jones
  • Gareth Lane
  • Michael Lett
  • Daniel Logan
  • Troy Luxton
  • Chris Mculloch
  • Francis McNaughton
  • Jason McNee
  • Adam Merriman
  • Adrian Moore
  • Karl Nuske
  • Tommy Prentice
  • Michael Quake
  • Damian Rees
  • Brad Saggers
  • Tim Schubert
  • Mitch Sumpton
  • Michael Teale
  • Drew Thompson
  • Graham Tooke
  • Matt Treasure
  • Louis Williams
  • Michael Wilson
  • Alan Brown
  • Lee Brown
  • Craig Busquets
  • David Clements
  • Reg Day
  • Lewis Harriman
  • Rob Jurjevich
  • Pat Middle
  • Trent Proctor
  • Dave Proctor
  • Kara Clements
  • Paul Clements

Job Details

• Job Number

• Job Name

• Client

  Select Amcom Optus Wavelength Downer Western Gas and Civil ODS Other-please specify

  • Amcom
  • Optus
  • Wavelength
  • Downer
  • Western Gas and Civil
  • ODS
  • Other-please specify

• other (if applicable)

Third Party Details

• Name

• Contact Number

• Address

• Registration Number

Service Damage

• Repairer

  Select Western Power Atco Gas Telstra Water Corporation Optus Amcom Diversified Other-(please specify)

  • Western Power
  • Atco Gas
  • Telstra
  • Water Corporation
  • Optus
  • Amcom
  • Diversified
  • Other-(please specify)

• Other

• Time repairer attended the site

  Date

• Time repairer departed the site

  Date

• Were the DBYD plans on site and in date?

  Yes

  No

  N/A

• Was the service physically located and marked out prior to commencing work

  Yes

  No

  N/A

• What alignment was the service on

• What was the depth of the service

Cause Analysis

Work Processes

• Photos of all pages of the JRA

  Media

• Have all additional hazards been identified and assessed using the Job Risk Assessment

  Yes

  No

  N/A

• Are the control measures listed adequate for the works?

  Yes

  No

  N/A

• Have all control measures listed in the SWMS and Risk Assessment been implemented?

  Yes

  No

  N/A

Vehicles, Plant, Equipment

• Was the equipment used appropriate for the task?

  Yes

  No

  N/A

• If no, is there appropriate equipment available to perform the task?

  Yes

  No

  N/A

• Was the equipment Pre-Started before use?

  Yes

  No

  N/A

• Has the equipment been maintained appropriately?

  Yes

  No

  N/A

• Was the equipment being used as the manufacturer intended?

  Yes

  No

  N/A

Environmental

• Did lighting levels contribute to the cause of this incident?<br>

  Yes

  No

  N/A

• Did noise levels contribute to the cause of this incident?

  Yes

  No

  N/A

• Did temperature contribute to the cause of this incident?

  Yes

  No

  N/A

• Did insufficient space contribute to the cause of this incident?

  Yes

  No

  N/A

• Did lack of warning signs contribute to the cause of this incident?

  Yes

  No

  N/A

• Do you believe any other environmental factors contributed to the cause of this incident?

  Yes

  No

  N/A

Competency Training

• How long has the person been performing this task?

• Is the person adequately trained to complete the task?

  Yes

  No

  N/A

Corrective/Preventative Action

• Do you believe that this could have been prevented?

  Yes

  No

  N/A

• What immediate action have you taken to ensure it does not happen again?

• What do you recommend Diversified should do to prevent a reoccurrence?

• Supervisor

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