Accident Investigation loss control template
Client (select from drop box)
Program I.e. UFB, RBI, NGA, BAU
Date of the incident
Location of incident
Name of persons or contractor involved
- Downer employee
- Customer employee
- Contractor employee
- Member of public
Type of incident
- lost time injury
- medical treatment
- first aid injury
- plant damage
- service safety critical strike
- serious harm
- environmental incident
- cardinal rule breach
Notify the Zero Harm Advisor immediately as per Downer policy
Do not remove items from the scene.
Do not interfere with the scene unless safety critical
Freeze and make scene safe, the scene is not to be disturbed under the requirements of the Health and Safety in Employment act 1992, and HSE Amendments Act 2002 unto. Approval has been obtained by a zero harm advisor for WorkSAFE nz.
Serious harm notification has been completed by phone, and hard copy provided to WorkSAFE nz (Former DoL).
Record vehicle plant damage information I.e. Rego, wof, include damage images in this report.
Ensure INF form is completed by the ZHA to senior management
Ensure INX number entered by the ZHA and INF submitted to senior ZH management - ZHA responsibility.
Ensure Zero Harm Advisor notified
Ensure the National Environmental and Sustainability Manager is notified
Ensure ESRM01 completed.
Select Cardinal Rule Applicable
- standing in path of mobile plant and machinery
- working at heights without controls
- confined space entry without permission
- standing under suspended loads
- isolation zones
- tampering with safety mechanisms
- unauthorised work on plant and equipment
- lock out tag out not present
- mobile phones or seatbelts
- Drugs an or alcohol, or impairing substances
ZERO HARM ADVISOR must be notified immediately!
ICAM Investigation must be undertaken
Considered high potential by default
Which parts of the body have been injured and describe extent of injury(s)
Describe the damage to the plant service and or equipment where possible.
Was a Drug and Alcohol test performed?
Results must be sent to the Zero Harm Advisor by TDDA 0508 (DRUG TEST)
Downer policy permits ;
- Post incident, and
- Just cause testing.
Refusal to submit for a drug and alcohol text on these grounds may result removal fro. Site pending further investigation may result in dismissal.
Test results must be provided to the individual and the zero harm team. Results must not be kept by any other person.
Record relevant images
Any relevant drawings
- First aid treatment
- Environmental controls
- Under investigation
- Asset Repaired
Described what happened?
Root Cause Analysis - 5 Whys
Corrective and Preventative Actions
Outline the corrective actions taken in response to this incident.
Action Plan & Timeline
Develop a action plan with timelines to address the corrective actions
RCA Team Member
RCA Team Member
EHS Team Member
Management are to ensure the actions identified in the report are closed out in proper timeliness as per the requirements of SPM 18 and the Downer NZ LTD accident investigation procedure and policy.
Actions should signed off by management with completion dates noted.
Records of activities are subject to auditing in accordance with Downer 4801 Safety Management Systems requirements.