• Document No.

  • Accident Investigation loss control template

  • Client (select from drop box)

  • Program I.e. UFB, RBI, NGA, BAU

  • Date of the incident

  • Date Reported

  • Prepared by

  • Location of incident
  • Name of persons or contractor involved

  • Employee/contractor/other(Select)

  • Type of incident

  • Legal requirements:

    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

  • 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

  • Actions taken

Investigation details

  • Described what happened?

Root Cause Analysis - 5 Whys

  • WHY 1.

  • WHY 2.

  • WHY 3.

  • WHY 4.

  • WHY 5.

Investigation Findings

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

  • Responsibilities:

    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.

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