SKMES Root Cause Investigation QA/QC

• Document No.

• Accident Investigation loss control template

• Client (select from drop box)

  Downer

  Chorus

  Vodafone

• Program I.e. UFB, RBI, NGA, BAU

  UFB

  RBI

  NGA

  BAU

• Date of the incident

  Date

• Date Reported

  Date

• Prepared by

• Location of incident
  Address

• Name of persons or contractor involved

• Employee/contractor/other(Select)

  Select Downer employee Customer employee Contractor employee Member of public Not-plicable

  • Downer employee
  • Customer employee
  • Contractor employee
  • Member of public
  • Not-plicable

• Type of incident

  Select lost time injury medical treatment first aid injury plant damage service safety critical strike serious harm environmental incident cardinal rule breach

  • lost time injury
  • medical treatment
  • first aid injury
  • plant damage
  • service safety critical strike
  • serious harm
  • environmental incident
  • cardinal rule breach

• 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).

  Yes

  No

  N/A

• 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

  Select 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

  • 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?

  Yes

  No

• 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

  Media

• Any relevant drawings

  Drawing

• Actions taken

  Select Nil First aid treatment Doctor Hospital Environmental controls Under investigation Asset Repaired

  • Nil
  • First aid treatment
  • Doctor
  • Hospital
  • Environmental controls
  • Under investigation
  • Asset Repaired

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

Signoff

• Name of person filing report and signature

  Sign

• Responsibilities:
  
  Operations is to ensure the actions identified in the report are closed out in conjunction with the Project Manager.
  
  Actions should be signed off by VP of Construction or Operations Manager with completion dates noted.