Incident Report V3

• Incident

• Incident Type

  Select Injury Near Miss Environmental Damage

  • Injury
  • Near Miss
  • Environmental
  • Damage

• F2020 #

• INX #

REPORTING INFORMATION

• Incident Description

• Name of involved Person

• Location

• Incident Date / Time

  Date

• Reported to

• Position reported

• Reported Date / Time

  Date

Asset Details

• Equipment Involved

  Select Prime Mover Trailer Loader Excavator Grader Bus Light Vehicle

  • Prime Mover
  • Trailer
  • Loader
  • Excavator
  • Grader
  • Bus
  • Light Vehicle

• Asset Number / s

Shift Details

• Roster Type

  2/1

  8/6

  12/9

  5/2

• Days into Roster

• Shift Start Time

  06:00

  18:00

• Type of Shift

  Day

  Night

• Shift Length

  8 Hours

  10 Hours

  12 Hours

INCIDENT DETAILS

• Detailed Description

• Diagram

  Drawing

• Photo 1

  Media

• Photo 2

  Media

• Immediate Actions Taken

PEEPO INVESTIGATION

PEOPLE

• PE1 Was a personal safety check completed?

  Yes

  No

  N/A

• PE2 were person / s experienced for the task?

  Yes

  No

  N/A

• PE3 had they been adequately trained?

  Yes

  No

  N/A

• PE4 did the person understand the task?

  Yes

  No

  N/A

• PE5 was the person deemed competent to perform the task?

  Yes

  No

  N/A

• PE6 Were they physically capable of undertaking the task?

  Yes

  No

  N/A

• PE7 was stress adequately managed?

  Yes

  No

  N/A

• PE8 was fatigue adequately managed?

  Yes

  No

  N/A

• PE9 did the incident occur during the persons normal roster?

  Yes

  No

  N/A

• PE10 Was PPE worn?

  Yes

  No

  N/A

• PE11 was the PPE worn correctly?

  Yes

  No

  N/A

• PE12 Was the person aware of the hazards associated with the task?

  Yes

  No

  N/A

• PE13 did the person involved adhere to accepted procedures / processes?

  Yes

  No

  N/A

ENVIRONMENT

• EN1 were weather conditions adequately managed?

  Yes

  No

  N/A

• EN2 Were any housekeeping issues adequately managed?

  Yes

  No

  N/A

• EN3 Was the location of the work area adequate for the task being undertaken?

  Yes

  No

  N/A

• EN4 Was the design of the work area adequate for the task being undertaken?

  Yes

  No

  N/A

• EN5 Was visibility adequate for the task being undertaken?

  Yes

  No

  N/A

• EN6 Was access/egress adequate?

  Yes

  No

  N/A

• EN7 Were toxic or hazardous materials adequately managed?

  Yes

  No

  N/A

• EN9 Were noise related issues managed?

  Yes

  No

  N/A

• EN10 Were roads / ground conditions up to standard?

  Yes

  No

  N/A

EQUIPMENT

• EQ1 Was the equipment operating as designed?

  Yes

  No

  N/A

• EQ2 Was the equipment being used adequate for the task?

  Yes

  No

  N/A

• EQ3 Was the appropriate equipment / tools available for the task?

  Yes

  No

  N/A

• EQ4 were all safety devices operational?

  Yes

  No

  N/A

• EQ5 Has maintenance been conducted as per schedule?

  Yes

  No

  N/A

• EQ6 Was a pre-start inspection conducted?

  Yes

  No

  N/A

• EQ7 was a documented risk assessment carried out on the equipment?

  Yes

  No

  N/A

PROCEDURES

• PR1 Were procedures available for the task?

  Yes

  No

  N/A

• PR2 were they used?

  Yes

  No

  N/A

• PR3 Did they anticipate / identify hazards that led to the incident?

  Yes

  No

  N/A

• PR4 Are they adequate for use?

  Yes

  No

  N/A

• PR5 was the person adequately trained?

  Yes

  No

  N/A

• PR6 Are required competencies documented?

  Yes

  No

  N/A

• PR7 Were area / location inspections conducted?

  Yes

  No

  N/A

ORGANISATION

• O1 Was there adequate and effective supervision available?

  Yes

  No

  N/A

• O2 Was training provided to personnel to conduct the task?

  Yes

  No

  N/A

• O3 Were any identified hazardous conditions corrected?

  Yes

  No

  N/A

• O4 Is there suitable availability of PPE?

  Yes

  No

  N/A

• O5 Are inspection / maintenance schedules adequately managed?

  Yes

  No

  N/A

Corrective Actions

Action 1

• Required Action

• Assigned To

• Due Date

  Date

Action 2

• Required Action

• Assigned To

• Due Date

  Date

Action 3

• Required Action

• Assigned To

• Due Date

  Date

Sign Off / Approval

• Investigation Leader

  Sign

• Comments

• Shift Supervisor

  Sign

• Comments

• Safety Representative

  Sign

• Comments

• HSE Advisor

  Sign

• Comments

• Site Manager / Delegate

  Sign

• Comments