SBC Near Miss / Notifiable Incident - Rev A

• Completed on

  Date

• Completed by

• Document No.

Reporting Person's Details

• Full Name

• Occupation

• Contact Number

• Designation

  Site Worker

  Site Visitor

  General Public

  Strongbuild Employee

• Is this a Notifiable Incident or a Near Miss?

  Notifiable Incident

  Near Miss

Near Miss Details

• Date and Time the Near Miss Occurred

  Date

• Weather Conditions

  Select Fine Overcast Light Shower Rain Thunderstorm Strong Winds Frost Heavy Dew/Ice Extreme Heat

  • Fine
  • Overcast
  • Light Shower
  • Rain
  • Thunderstorm
  • Strong Winds
  • Frost
  • Heavy Dew/Ice
  • Extreme Heat

• What task was being performed at the time of the near miss?

• How did the near miss occur?

• What was the location on site where the near miss occurred? ( Building / Level / Unit / Room )

Third Party Property Damage

• Was there any third party property damage?

  Yes

  No

  N/A

• Provide Details

Witness Observations

• Were there any witnesses to the actual event?

  Yes

  No

  N/A

• Witness Details

Witness

• Full Name

• Employer

• Occupation

• Designation

  Site Worker

  Site Visitor

  General Public

  Strongbuild Employee

• Contact Number

• Observations

Contributing Factors

• Where Any Contributing Factors Identified?

  Select No Improper use of equipment Equipment failure Worker not properly trained in use of equipment Unauthorised use of equipment Poor housekeeping Lack of warning/safety signage Work zone not isolated Materials not stacked correctly Materials not tied down/or insufficient tie downs Weather Conditions Horseplay Other

  • No
  • Improper use of equipment
  • Equipment failure
  • Worker not properly trained in use of equipment
  • Unauthorised use of equipment
  • Poor housekeeping
  • Lack of warning/safety signage
  • Work zone not isolated
  • Materials not stacked correctly
  • Materials not tied down/or insufficient tie downs
  • Weather Conditions
  • Horseplay
  • Other

• Provide Details

Preventative Actions

• Have strategies have been implemented to prevent a re-occurrence? (Strategies must be included using the Actions/Notes function)

  Yes

  No

  N/A

• Provide reasons

Timeline

• Do you wish to build a timeline of events?

  Yes

  No

  N/A
Event

• Select date

  Date

• Description of event

Notifiable Incident

• All Notifiable Incidents must be reported to SafeWork NSW 13 10 50.
  You must provide the following information:
  - An overview of the incident
  - The time it occurred
  - The address and location on site the incident occurred
  - Measures taken to prevent a re-occurrence.
  - The Strongbuild entity ABN
  - Strongbuild Commercial Pty Ltd 30 150 279 637
  -Strongbuild Pty Ltd 65 150 268 438

• Reference - WHS Act Part 3
  https://www.legislation.nsw.gov.au/#/view/act/2011/10/part3

• What type of Notifiable Incident is it?

  Select An uncontrolled escape, spillage or leakage of a substance An uncontrolled implosion, explosion or fire An uncontrolled escape of gas or steam An uncontrolled escape of a pressurised substance Electric shock The fall or release from a height of any plant, substance or thing The collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations The collapse or partial collapse of a structure The collapse or failure of an excavation or of any shoring supporting an excavation The inrush of water, mud or gas in workings, in an underground excavation or tunnel The interruption of the main system of ventilation in an underground excavation or tunnel

  • An uncontrolled escape, spillage or leakage of a substance
  • An uncontrolled implosion, explosion or fire
  • An uncontrolled escape of gas or steam
  • An uncontrolled escape of a pressurised substance
  • Electric shock
  • The fall or release from a height of any plant, substance or thing
  • The collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations
  • The collapse or partial collapse of a structure
  • The collapse or failure of an excavation or of any shoring supporting an excavation
  • The inrush of water, mud or gas in workings, in an underground excavation or tunnel
  • The interruption of the main system of ventilation in an underground excavation or tunnel

• Date and Time the Notifiable Incident Occurred

  Date

• Weather Conditions (if known, at time of the incident)

  Select Fine Overcast Light Shower Rain Thunderstorm Strong Winds Frost Heavy Dew/Ice Extreme Heat

  • Fine
  • Overcast
  • Light Shower
  • Rain
  • Thunderstorm
  • Strong Winds
  • Frost
  • Heavy Dew/Ice
  • Extreme Heat

• What task was being performed at the time of the Notifiable Incident occurred?

• How did the Notifiable Incident occur?

• What was the location on site where the Notifiable Incident occurred? ( Building / Level / Unit / Room )

• Photos

  Media

Third Party Property Damage

• Was there any third party property damage?

  Yes

  No

  N/A

• Provide Details

Witness Observations

• Were there any witnesses to the actual event?

  Yes

  No

  N/A

• Witness Details

Witness

• Full Name

• Employer

• Occupation

• Designation

  Site Worker

  Site Visitor

  General Public

  Strongbuild Employee

• Contact Number

• Observations

Contributing Factors

• Where Any Contributing Factors Identified?

  Select No Improper use of equipment Equipment failure Worker not properly trained in use of equipment Unauthorised use of equipment Poor housekeeping Lack of warning/safety signage Work zone not isolated Materials not stacked correctly Materials not tied down/or insufficient tie downs Weather Conditions Horseplay Other

  • No
  • Improper use of equipment
  • Equipment failure
  • Worker not properly trained in use of equipment
  • Unauthorised use of equipment
  • Poor housekeeping
  • Lack of warning/safety signage
  • Work zone not isolated
  • Materials not stacked correctly
  • Materials not tied down/or insufficient tie downs
  • Weather Conditions
  • Horseplay
  • Other

• Provide Detail

Preventative Actions

• Have strategies have been implemented to prevent a re-occurrence? (Strategies must be included using the Actions/Notes function)

  Yes

  No

  N/A

• Provide reasons

Timeline

• Do you wish to build a timeline of events?

  Yes

  No

  N/A
Event

• Select date

  Date

• Description of event

SafeWork NSW Details

• Date and Time reported

  Date

• Name of SafeWork NSW representative you spoke to on the phone

• SafeWork NSW reference number

• Did SafeWork NSW release the site?

  Yes

  No

  N/A

• What instructions were given by SafeWork NSW?

• Add media

  Media