Title Page
RCC Incident Investigation Report Form
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Use this form to investigate any workplace incident where the incident has a risk potential of High or Medium.
Use section 2 to determine whether the incident meets this criteria. -
Investigation report title "WHS incident investigation for Damstra event
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Unit name
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Conducted on
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Investigated by
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Location
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Investigation team
Section 1. Incident details
Details of the incident
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Date and time of incident
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A person was injured.
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Please add injured person
(click '+' to add another injured person)
Person
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Name
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A person witnessed the incident.
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Please add witness details
(click '+' to add another witness)
Person
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Name
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Have photos of the incident site been taken and are they attached?
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Do not proceed unless photo(s) is taken.
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Where did the incident occur?
Section 2. Risk potential
Risk Potential Calculation
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Consider the likelihood and the consequence of the incident to determine the potential level of risk associated with this incident.
Likelihood
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Very Likely - The event will happen more often than not.
Likely - The event has happened, including elsewhere, with regular occurrence.
Unlikely - The event could happen occasionally/occurs somewhere from time to time/unusual but possible.
Very Unlikely - Could happen, but probably never will/have not known of event occurring. -
The potential Likelihood of this event occurring is:
Consequence
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Extreme - Death; permanent disability
Major - Reversible bodily injury requiring hospital admittance
Moderate - Reversible bodily injury requiring medical treatment (without hospital admittance)
Minor - No injury/first aid only, no lost work time -
The potential Consequence of this event occurring is:
Risk Rating
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The risk rating has been calculated and = 1.
The potential risk is therefore HIGH and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 2.
The potential risk is therefore HIGH and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 3.
The potential risk is therefore HIGH and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 4.
The potential risk is therefore MEDIUM and a documented incident investigation IS necessary
Consequence
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Extreme - Death; permanent disability
Major - Reversible bodily injury requiring hospital admittance
Moderate - Reversible bodily injury requiring medical treatment (without hospital admittance)
Minor - No injury/first aid only, no lost work time -
The potential Consequence of this event occurring is:
Risk Rating
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The risk rating has been calculated and = 2.
The potential risk is therefore HIGH and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 3.
The potential risk is therefore HIGH and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 4.
The potential risk is therefore MEDIUM and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 5.
The potential risk is therefore MEDIUM and a documented incident investigation IS NOT necessary
Consequence
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Extreme - Death; permanent disability
Major - Reversible bodily injury requiring hospital admittance
Moderate - Reversible bodily injury requiring medical treatment (without hospital admittance)
Minor - No injury/first aid only, no lost work time -
The potential Consequence of this event occurring is:
Risk Rating
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The risk rating has been calculated and = 3.
The potential risk is therefore HIGH and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 4.
The potential risk is therefore MEDIUM and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 5.
The potential risk is therefore MEDIUM and a documented incident investigation IS NOT necessary
Risk Rating
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The risk rating has been calculated and = 6.
The potential risk is therefore LOW and a documented incident investigation IS NOT necessary
Consequence
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Extreme - Death; permanent disability
Major - Reversible bodily injury requiring hospital admittance
Moderate - Reversible bodily injury requiring medical treatment (without hospital admittance)
Minor - No injury/first aid only, no lost work time -
The potential Consequence of this event occurring is:
Risk Rating
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The risk rating has been calculated and = 4.
The potential risk is therefore MEDIUM and a documented incident investigation IS necessary
Risk Rating
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The risk rating has been calculated and = 5.
The potential risk is therefore MEDIUM and a documented incident investigation IS NOT necessary
Risk Rating
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The risk rating has been calculated and = 6.
The potential risk is therefore LOW and a documented incident investigation IS NOT necessary
Risk Rating
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The risk rating has been calculated and = 7.
The potential risk is therefore LOW and a documented incident investigation IS NOT necessary
Section 3. Factual Description
Pre event
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List the events leading up to the incident.
The event
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Describe what occurred at the moment of the incident.
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Did something occur unexpectantly for the event to have taken place?
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Explain.
Post event
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Was first aid provided?
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Explain.
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Describe what controls were implemented immediately following the event.
The postives
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What went well?
Section 4. Contributing factors
Contributing factors
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What factors appear to have contributed to the incident?
The examples given should be used as prompts. Detail MUST be provided for at least one contributing factor.
1. People
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• Experienced in the work being performed?
• Adequately trained or skilled?
• Physically capable?
• Tired, fatigued or bored?
• Under stress (work or personal)? -
Did the injured person/another person contribute to the event occuring?
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Explain
Preventative actions
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Tick the appropriate preventative action and provide details below. More than one preventative action group can be selected.
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Change to Plant / Equipment
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Click on the "Action" button above to add an action. More than one action can be created.
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Change to Procedures
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Click on the "Action" button above to add an action. More than one action can be created.
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Staff Training / Prestart / Instruction
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Click on the "Action" button above to add an action. More than one action can be created.
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Other
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Click on the "Action" button above to add an action. More than one action can be created.
2. Plant & Equipment
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• Effective and regular preventative equipment maintenance?
• Regular plant pre-operating safety inspections carried out?
• Purchasing process to buy appropriate equipment which is best suited for task?
• Appropriately designed tools, equipment or furniture available?
• Testing & tagging systems, out of service systems to withdraw faulty or damaged equipment.
• Safety devices were working properly? -
Did plant and/or equipment contribute to the event occuring?
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Explain
Preventative actions
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Tick the appropriate preventative action and provide details below. More than one preventative action group can be selected.
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Change to Plant / Equipment
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Click on the "Action" button above to add an action. More than one action can be created.
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Change to Procedures
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Click on the "Action" button above to add an action. More than one action can be created.
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Staff Training / Prestart / Instruction
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Click on the "Action" button above to add an action. More than one action can be created.
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Other
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Click on the "Action" button above to add an action. More than one action can be created.
3. Work or Natural Environment
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• Weather conditions at the time were safe for the task to continue?
• Basic housekeeping or space for manoeuvring available?
• Extremes of heat or cold – weather or generated from a process?
• Noise does not distract or interfere with alarm signals?
• Adequate lighting for the detail of the task?
• Working atmosphere is well ventilated? -
Did the work or natural environment contribute to the event occuring?
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Explain
Preventative actions
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Tick the appropriate preventative action and provide details below. More than one preventative action group can be selected.
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Change to Plant / Equipment
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Click on the "Action" button above to add an action. More than one action can be created.
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Change to Procedures
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Click on the "Action" button above to add an action. More than one action can be created.
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Staff Training / Prestart / Instruction
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Click on the "Action" button above to add an action. More than one action can be created.
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Other
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Click on the "Action" button above to add an action. More than one action can be created.
4. Work Procedures, Methods or Tasks
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• Safe work procedure or method in existence and being followed?
• Normal/ abnormal operating conditions and appropriate methods used?
• Lockouts or tagout or other isolation systems were being used?
• Safe operating speeds, work production schedules or demands? -
Did the work procedures, methods or tasks contribute to the event occuring?
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Explain
Preventative actions
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Tick the appropriate preventative action and provide details below. More than one preventative action group can be selected.
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Change to Plant / Equipment
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Click on the "Action" button above to add an action. More than one action can be created.
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Change to Procedures
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Click on the "Action" button above to add an action. More than one action can be created.
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Staff Training / Prestart / Instruction
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Click on the "Action" button above to add an action. More than one action can be created.
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Other
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Click on the "Action" button above to add an action. More than one action can be created.
Section 5. Investigator's Notes
Notes from the Investigator
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Other pertinent information
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Notes
Section 6. Signatures
Investigator/Investigation Team
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Add Investigator's name
(click '+' to add another investigator)
Name
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Signature
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Role
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Contact number
