TechSafe Australia - Shock & Incident Investigation Report

• Document Number

• Electrical Fire, Shock & Incident report.
  

• Date report created

  Date

• Attended and reported by TechSafe Australia represented by:

• Attending authorised officers name:

  Select Clayton Davies Damian Grubb Richard Tattersall David Lynch Graeme Loosemore Martin Daniel Chris Broad Tim Hopper Grant Watkins Phil Whitmore Paul Jones Nigel Allen John Citizen

  • Clayton Davies
  • Damian Grubb
  • Richard Tattersall
  • David Lynch
  • Graeme Loosemore
  • Martin Daniel
  • Chris Broad
  • Tim Hopper
  • Grant Watkins
  • Phil Whitmore
  • Paul Jones
  • Nigel Allen
  • John Citizen

Details

• Incident Category:

  Select Fatality Serious Injury Minor Injury Electric Shock High Voltage Injection Minor Property Damage Significant Property Damage Fire Highly Unsafe Situation Technical Defect Disconnection/Isolation of supply Other (specify)

  • Fatality
  • Serious Injury
  • Minor Injury
  • Electric Shock
  • High Voltage Injection
  • Minor Property Damage
  • Significant Property Damage
  • Fire
  • Highly Unsafe Situation
  • Technical Defect
  • Disconnection/Isolation of supply
  • Other (specify)

• Date/time request to attend received:

  Date

• Request to attend from:

  Tasmanian Fire Service

  The Department of Justice Tasmania (ESS)

  The Tasmania Police

  TechSafe Management

• Date/time event took place:

  Date

• As informed by (name):

• Date/Time of arrival at site:

  Date

• Date/time of departure from site:

  Date
• Incident Address:
  Address

• Location type:

  Select Commercial Residential Agricultural Industrial Construction Public place Other

  • Commercial
  • Residential
  • Agricultural
  • Industrial
  • Construction
  • Public place
  • Other

• Specific location within the site:

Injured persons or deceased persons details:

• Name:

• Home Address:
  Address

• Gender:

  Male

  Female

• Contact number:

• Known Injuries:

  Select No shock or injury Electric shock Electric burns Flash burns Injuries from fall Fatal Other

  • No shock or injury
  • Electric shock
  • Electric burns
  • Flash burns
  • Injuries from fall
  • Fatal
  • Other

• Details of other injury type:

• Does this injury appear to be a serious electrical accident:

  Yes

  No

  Unknown

• Part of body injured:

  Select Head Neck Arms Legs Eyes Trunk Hands Feet Fingers Other

  • Head
  • Neck
  • Arms
  • Legs
  • Eyes
  • Trunk
  • Hands
  • Feet
  • Fingers
  • Other

• Known medical treatment type:

  Select no treatment Check up hospitalisation/Medical treatment Resuscitation

  • no treatment
  • Check up
  • hospitalisation/Medical treatment
  • Resuscitation

• Was shock sustained during the course of carrying out work for an employer:

  Yes

  No

  Unknown

• Name of employer:

• Address of employer:
  Address

• Contact number:

If an electrical appliance was involved please supply details:

• Category:

  Select Portable Stationary Fixed

  • Portable
  • Stationary
  • Fixed

• Class:

  Class I

  Class II

• Type of electrical appliance involved:

• Appliance Brand:

• Model number:

• Regulatory Compliance Mark:

• Approval number:

• Appliance age (years):

• Condition:

  Good

  Fair

  Poor

  Unknown

• Purchase details if known:

• Was an RCD installed on the circuit:

  Yes

  No

  Unknown

• Manufacturer of RCD:

• Rating of RCD:

• Did RCD operate:

  Yes

  No

• RCD tests undertaken:

  Yes

  No

• RCD trip times:

• RCD trip values:

• Photos of scene:

  Media

• External structure, House number, switchboard (if relevant), Other areas working in to the area of origin, close ups for detail where necessary.

• Diagram if required:

  Drawing

• Observations made (include at what point of the investigation the observations were made and where)

Comments made by person(s) on site:

• Name of person whom made comment:

• Comments made:

• Time comments were made:

  Date
Physical evidence collected from site:

• Items collected to support findings:

• Additional Information:

• Further actions taken by me were:

• Conclusion:

  Sufficient evidence could not be obtained to for a view

  Several scenarios exist as possible causes

  A probable cause can be determined

• I could not obtain sufficient information to form a view as to the most probable cause of the fire.

• Several scenarios exist as possible causes of ignition the following have been considered;

Scenario:

• Although other scenarios may exist, it is my belief that based on the information above information observed and/or obtained, the ignition source of the fire was most probably

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