Information
Details of Incident
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Name of Employee Completing Report
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Project Incident Occurred on (Including Project No.)
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Date & Time of Incident
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Location of Incident
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Add a photo(s) of location
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Incident Report Prepared by
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Weather and Site Conditions at Time of Incident
Plant / Equipment Information
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Use this section to record details of any vehicles, plant or equipment involved or related to the incident.
Plant / Equipment
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Name / ID
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Add a Photo(s)
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Owner (IPPL, Hired, etc.)
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Registration Number
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Asset ID Number
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Serial Number
WHAT HAPPENED?
Type of Incident
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What Type of Incident Has Occurred?
- Minor Property Damage (e.g. Immediately Repairable, <$500
- Minor Plant Damage (e.g. Still operable without creating risk, damage <$1000
- Minor Stakeholder Complaint (e.g. Issues Remedied Immediately and Closed out)
- Other - Minor (No impact to works, No Delay, Immediate Action Can Be Taken to Address/Close, Less than <$1000)
- Major Property Damage (e.g. Unable to be repaired immediately, >$500)
- Major Plant Damage / failure (e.g. Incapacitation of plant, Damage to plant >$1000, Delays project)
- Major Stakeholder Complaint (e.g. Works Stopped)
- Loss of production Materials (e.g. Exotherm, Damage to Liner / Materials)
- Environmental Incident (e.g. Spill, Contamination)
- Fire / Explosion
- Other - Major (>$1000, Delays works, unable to be fixed / closed immediately)
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Is the Incident Minor or Major?
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An Investigation will need to be completed for this Incident
Authorities Notified of Incident
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You need to detail in this section any notifications of the incident that have been made. This includes to emergency services (Fire, Ambulance, Police), Council, Client, EPA, etc.
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Were Authorities Notified?
Notification made to
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Authority Name
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Name of Person Notified
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Contact Number
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Reference Number from Authority
Description of the Incident
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Briefly Describe What happened
ROOT CAUSE
Who Was Involved / Witnessed The Incident? Who Was At The Scene?
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Person
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Name
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Relationship to IPPL (employee, client, resident, etc.)
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Contact Details
Description of How the Incident Has Occured
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In this section explain clearly how the Incident occurred; describe the events, conditions, activities being carried out - BEFORE, DURING and AFTER the incident - include details of the environment and work conditions, the extent of damage, etc.
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Enter Details
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Add photos
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Include a sketch if required
Witness Statement(s)
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Use this section to record details of any witnesses to the injury and record statements
Witness
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Name of Witness
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Company
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Contact Number
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Statement of Events
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Signature
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Add any photos necessary
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Include a sketch if necessary
NOTIFICATIONS
Supervisor (Mandatory)
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Supervisor needs to be notified immediately by phone call or SMS of the incident.
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Supervisor Name
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Date and Time of Notification to Supervisor
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Method of Notification
Project Manager (Mandatory)
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Project Manager needs to be notified immediately by phone call or SMS of the incident and needs a completed Incident form by close of business on the day the Incident occurred.
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Project Manager Name
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Date and Time of Notification to Project Manager
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Method of Notification
QSE (If Required)
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QSE Manager needs to be notified immediately by phone call for all Major Incidents and needs to have a completed Incident Form by Close of Business on the day of the Incident.
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Project Manager Name
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Date and Time of Notification to Project Manager
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Method of Notification
CORECTIVE ACTIONS AND PREVENTATIVE ACTIONS (CAPA)
Immediate Corrective Actions
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use this section to enter details of immediate corrective actions taken to control the incident.
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Immediate Corrective actions Undertaken
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Add any photos necessary
Preventative Actions
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Use this section to record details of any preventative actions put in place or to be undertaken to prevent the possibility of a similar incident occurring
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Preventative Actions undertaken
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Add any photos necessary
