TechSafe Australia - Shock & Incident Investigation Report V1.1

• Location of incident

• Document Number

• Electrical 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 Loosmore Martin Daniel Chris Broad Timothy Hopper Grant Watkins Phillip Whitmore Paul Jones Nigel Allen John Citizen

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

Details

• Incident Category

  Electric Shock

  High Voltage Injection

  Highly Unsafe Situation

  Disconnection/Isolation of supply

  Other (specify)

• Incident Consequences:

  Select Minor property damage significant property damage serious injury minor injury fatality no signs of physical injury unable to assess

  • Minor property damage
  • significant property damage
  • serious injury
  • minor injury
  • fatality
  • no signs of physical injury
  • unable to assess

• 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

  Tas Networks

• Date/time event took place:

  Date

• As informed by (name):

• Date/Time of arrival at site:

  Date

• Details of other persons onsite

• 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:

• Description of incident

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

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

  Yes

  No

  Unknown

  N/A

• 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

  N/A

• Injured persons occupation

  Non electrical industry worker

  electrical industry worker

  Distribution company worker

• Name of employer:

• Address of employer:
  Address

• Contact number:

If an electrical appliance was involved please supply details:

• Category:

  Portable

  Stationary

  Fixed

• Class:

  Class I (earthed appliance)

  Class II (double insulated appliance)

• 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

  N/A

• Manufacturer of RCD:

• Rating of RCD:

• Did RCD operate:

  Yes

  No

  Unknown

  N/A

• RCD tests undertaken:

  Yes

  No

• RCD trip times:

• RCD trip values:

• Would you expect the RCD to have operated

  yes

  no

Site tests

voltage between points of contact
independent Earth voltage tests
earth continuity tests
installation resistance test's
network analyser tests
RCD tests
other tests

• 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:

• Defect notice issued to owner/occupier

  yes

  no

• DEI Number

• Conclusion:

  no defective installation identified

  fault found on distribution asset

  fault found on electrical installation

• An inspection of the installation where the reported incident occurred found nothing defective or unsafe at the installation

• A fault was found on the distribution asserts which was:

• Defects were found at the installation which were

• Date/time of departure from site:

  Date

• Voltage between points of contact at time of site departure (if attending shock)

• This report is based on facts and evidence available at the time of the investigation

• Add signature

  Sign