Lraki Accident Incident Investigation

• INCIDENT TITLE

• Accident Details

• Location
  Address

• Date of Incident

  Date

• Time of incident

  Date

• Type

  Select Lost Time injury Medical Treatment Injury Minor First Aid Injury Restricted Work Injury Contractor Injury Near Miss ENOP Hazard Property Damage Environment

  • Lost Time injury
  • Medical Treatment Injury
  • Minor First Aid Injury
  • Restricted Work Injury
  • Contractor Injury
  • Near Miss
  • ENOP
  • Hazard
  • Property Damage
  • Environment

INTRODUCTION

• Summary of Incident

• Immediate Actions

INVESTIGATION TEAM

• Team Leader

• Team Names

INDICATION OF INJURIES

• Where there any injuries?

  YES

  NO

• Details of person(s) involved in incident

• Employment Status

  Select Permanent Casual/temp Contractor

  • Permanent
  • Casual/temp
  • Contractor

• Details of Injury

• Photographs

  Media

• Select area of injury?

  Select 1) Head 2) Neck 3) Chest 4) Adbomen 5) Shoulder 6) Arms 7) Elbow 8) Forearm 9) Wrist 10) Hand 11) Hip 12) Thigh 13) Knee 14) Calf 15) Top of foot 16) Foot 17) Nape 18) Lumber region 19) Buttock

  • 1) Head
  • 2) Neck
  • 3) Chest
  • 4) Adbomen
  • 5) Shoulder
  • 6) Arms
  • 7) Elbow
  • 8) Forearm
  • 9) Wrist
  • 10) Hand
  • 11) Hip
  • 12) Thigh
  • 13) Knee
  • 14) Calf
  • 15) Top of foot
  • 16) Foot
  • 17) Nape
  • 18) Lumber region
  • 19) Buttock

INDICATION OF DAMAGE TO PROPERTY/ KEY PLANT INVOLVED

• Was there any Property Damage?

  YES

  NO

• Photographs of damage

  Media

• Key Plant and Equipment involved in Incident

  YES

  NO

• Equipment Name, Serial number, Manufacturer, managed by?

• Photographs

  Media

WITNESSES

• Where there any witnesses?

  YES

  NO

• Record Details Of Witnesses

INVESTIGATION DETAIL

• Sketch / diagram if required

  Drawing

• Pre -incident Events (list activities occurring prior to the incident)

• Sequence Of Events (list the event in chronological order)

• Post Incident Events (list the activities undertaken after the event)

OBSERVATIONS (include any contributing factors)

• Oservations

  Select Inadequate guarding Inadequate lighting Inadequate/lack of training Inadequate/lack of work procedures Exposure to electricity Use of incorrect tools/equipment Incorrect manual handling equipment Lack of supervision Exposure to chemicals/hazardous substances Exposure to sound/noise Congested Work areas/poor housekeeping Faulty equipment/materials Lack of PPE Fire/Explosion No Risk Assessments No safety equipment Other

  • Inadequate guarding
  • Inadequate lighting
  • Inadequate/lack of training
  • Inadequate/lack of work procedures
  • Exposure to electricity
  • Use of incorrect tools/equipment
  • Incorrect manual handling equipment
  • Lack of supervision
  • Exposure to chemicals/hazardous substances
  • Exposure to sound/noise
  • Congested Work areas/poor housekeeping
  • Faulty equipment/materials
  • Lack of PPE
  • Fire/Explosion
  • No Risk Assessments
  • No safety equipment
  • Other

• Other Provide Details?

CONCLUSIONS (immediate cause and contributing factors)

• CONCLUSIONS?

Individual and Team Actions

• Select supervisory error or violation operating error or violation PPE error or violation procedural compliance change management error hazard management error or violation work method error or violation occupational hygiene practices other

  • supervisory error or violation
  • operating error or violation
  • PPE error or violation
  • procedural compliance
  • change management error
  • hazard management error or violation
  • work method error or violation
  • occupational hygiene practices
  • other
Task and Environmental Conditions - Workplace

• Select task planning hazard analysis/job safety analysis work procedures availability and suitability permit to work availability and suitability abnormal operational situation/condition equipment/materials condition/availability housekeeping weather conditions congestion/restricted access routine/non routine task fire and/or explosion hazard lighting noise gas/dust/fumes and ventilation radiation chemical wildlife surface gradient other

  • task planning
  • hazard analysis/job safety analysis
  • work procedures availability and suitability
  • permit to work availability and suitability
  • abnormal operational situation/condition
  • equipment/materials condition/availability
  • housekeeping
  • weather conditions
  • congestion/restricted access
  • routine/non routine task
  • fire and/or explosion hazard
  • lighting
  • noise
  • gas/dust/fumes and ventilation
  • radiation
  • chemical
  • wildlife
  • surface gradient
  • other
Task and Environmental Conditions - Human Factors

• Select personality/attitude/beliefs drugs/alcohol influence tolerance of violations fatigue situational awareness time pressures peer pressure/supervisory example physical/mental stress secondary goals distraction/pre-occupation competency/experience poor communications change of routine reliance on undocumented knowledge other human factor

  • personality/attitude/beliefs
  • drugs/alcohol influence
  • tolerance of violations
  • fatigue
  • situational awareness
  • time pressures
  • peer pressure/supervisory example
  • physical/mental stress
  • secondary goals
  • distraction/pre-occupation
  • competency/experience
  • poor communications
  • change of routine
  • reliance on undocumented knowledge
  • other human factor
Organisational Factors

• Select hardware training organisation communication incompatible goals procedures maintenance management design risk management management of change contractor management organisational culture regulatory influence organisational learning vehicle management management systems

  • hardware
  • training
  • organisation
  • communication
  • incompatible goals
  • procedures
  • maintenance management
  • design
  • risk management
  • management of change
  • contractor management
  • organisational culture
  • regulatory influence
  • organisational learning
  • vehicle management
  • management systems
Absent or failed defences

• Select alarm systems guarding control systems emergency systems safety/environment device operation PPE safe work instruction hazard identification risk controls supervision other

  • alarm systems
  • guarding
  • control systems
  • emergency systems
  • safety/environment device operation
  • PPE
  • safe work instruction
  • hazard identification
  • risk controls
  • supervision
  • other

RECOMMENDATIONS (include any corrective, preventive actions)

• Recommendations? (Action, responsible, completion date)

FURTHER ACTIONS

• Further Actions

  Select Has the immediate cause been established? Is verification required at any point? Does a Safety Alert need producing?

  • Has the immediate cause been established?
  • Is verification required at any point?
  • Does a Safety Alert need producing?

PHOTOGRAPHS

• Photographs

  Media

REPORT COMPLETED BY

• INVESTIGATION COMPLETED BY:

  Sign

• DATE

  Date

• Report Distribution