Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
Incident Date
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Select date
Incident Location
Investigation Team
Corrective and Preventative Actions
Incident Detail
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Company Impacts (business interruption etc)
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Medical Treatment
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Risk Rating
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Damage to Equipment
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Total Incident Cost
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Environmental Impact
Incident Description
Incident Timeline (list critical events)
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Select date
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Select date
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Select date
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Select date
Witness statements
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Add media
Sketches or diagrams
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Add drawing
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Add media
PEEPO (Procedures, Equipment, Environment, People, Organisation
Procedures or Work Method
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Were procedures available for the task?
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Were the procedures used? Correct version?
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Did the procedures anticipate or identify the risks that led to the incident?
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Are required competencies documented?
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Are equipment registers/logbooks used and reviewed regularly?
Equipment
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Faulty or failing equipment?
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Was design or quality of equipment a factor?
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Appropriate equipment/tools available?
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Was equipment working within its limitations?
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Were any safety devices inoperative at time of incident?
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Were any modifications made to the equipment?
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Has maintenance been conducted as per the schedule/plan?
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Are regular inspections/pre-start checks conducted on equipment?
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Was a Lockout / Isolation conducted if required?
Environment
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Were weather conditions a factor?
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Were any house keeping issues involved?
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Did the location of the work area contribute?
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Visibility?
People
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Were persons experienced in task?
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Had they been adequately trained?
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Has competency been documented?
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Was fatigue a factor?
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Was PPE required and or worn appropriately?
Organisation
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Was there adequate and effective supervision available?
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Have similar incidents occurred previously?
Absent or failed defences - these are systems designed to protect the overall system from the results of human or technical failures - the 'last minute' protection designed to avoid a bad outcome. Tick the ones that are contributing factors.
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Detection systems
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Protection systems
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Warning systems
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Guards or barriers
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Control systems
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Recovery or backup systems
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Escape systems
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Rescue systems
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Safety Device Operation
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PPE suitability/avaliablity
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Safe work instructions
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Hazard ID/Awareness
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Risk controls
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Supervision
Individual / Team Action
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Unintended Slip - errors mainly due to inattention, distraction or poor vigilance. Usually occur during well-practised and familiar tasks in which our actions are mostly automatic.
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Unintended Mistake - poor judgement or decision making.
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Mistake type:
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Unintended Lapse - failure to carry out an action due to memory failure.
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Intended Violation - deliberate deviation from safe operating procedures, standards or rules.
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Violation type:
- Rotuine - habitual corner cutting, accepted practice
- Situational - time or resource presures
- Personal optimising - personal convenience, suits self
- Organisational optimising - commercial or production goals override safety goals
- Exceptional - unusual emergency circumstances
- Reckless - deliberate, not caring or thinking of consequences
Task / Environmental Conditions - refer to lists on page 42-43
Workplace
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Error Factors - Workplace
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Error Factors - Human
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Common Factors - Workplace
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Common Factors - Human
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Violation Factors - Workplace
Organisational Failures - Basic Causes - Page 44 pocket guide.
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Hardware
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Training
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Organisation
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Communication
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Incompatible Goals
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Procedures
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Maintenance Management
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Design
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Risk Management
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Management of Change
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Contractor Management
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Organisational Culture
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Regulatory Infuence
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Organisational Learning
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Vehicle Management
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Violation Factors - Human
Conclusions or Observations
Sign Off: Acceptance of findings and comments
Activity Manager (relevant area):
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Add signature
General Manager (relevant area):
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Safety and Environmental Risk Manager:
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CEO:
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