TechSafe Australia - Shock Investigation Report

• Address

• Conducted on

  Date

• TechSafe Australia Job Number

• Electrical Shock & Incident report.
  

• Date report created

  Date

• Attended and reported by TechSafe Australia representative:

• 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 reported as:

  Electric Shock

  High Voltage Injection

  Highly Unsafe Situation

  Disconnection/Isolation of supply

  Other (specify)

• Treatment received

  No treatment

  Medical check up

  Hospitalisation/Medical treatment

  Resuscitation

  Unknown

• 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)

  Tasmania Police

  TechSafe Management

  TasNetworks

• Date/Time of arrival at site:

  Date

• Details of other relevant persons onsite

• Incident took place

  Select At a specific time, which was: At approximately: Several days before notification Several weeks before notification Several months before notification Has been regularly occurring for some time

  • At a specific time, which was:
  • At approximately:
  • Several days before notification
  • Several weeks before notification
  • Several months before notification
  • Has been regularly occurring for some time

• Specific date/time event took place

  Date

• Approximate date/time event took place

  Date

• Notified of incident details by

  TasNetworks

  WorkSafe Tas

  other

• Name, contact details and relevance of person to incident

• 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

Person who received shock or injury details:

• Name:

• Home Address:
  Address

• Gender:

  Male

  Female

• Contact number:

• Injuries and treatment details:

  Select No injury Physical Injury Electrical burns Flash burns Injuries from fall Fatality Other

  • No injury
  • Physical Injury
  • Electrical burns
  • Flash burns
  • Injuries from fall
  • Fatality
  • Other

• Severity of injury/shock

  Slight

  Strong

  Severe

• Part of body:

  Select Head Neck Arm(s) Leg(s) Eye(s) Trunk Hand(s) Feet Finger(s) Other

  • Head
  • Neck
  • Arm(s)
  • Leg(s)
  • Eye(s)
  • Trunk
  • Hand(s)
  • Feet
  • Finger(s)
  • Other

• Known medical treatment type:

  Select No treatment Medical check up Hospitalisation/Medical treatment Resuscitation Unknown

  • No treatment
  • Medical check up
  • Hospitalisation/Medical treatment
  • Resuscitation
  • Unknown

• Detail injury

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

  Yes

  No

  Unknown

  N/A

  Self employed

• Injured persons occupation

  Non electrical industry worker

  electrical industry worker

  Distribution company worker

• Name of employer:

• Address of employer:
  Address

• Contact number:

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

  Yes

  No

  Unknown

  N/A

  Self employed

• Electrical appliance

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 (approximation):

• Condition:

  Good

  Fair

  Poor

  Unknown

• Purchase details if known:

RCD Details

• Was an RCD installed on the circuit:

  Yes

  No

  Unknown

  N/A

  Self employed

• Manufacturer of RCD:

• Trip rating of RCD:

• Did RCD operate:

  Yes

  No

  Unknown

  N/A

  Self employed

• RCD tests undertaken:

  Yes

  No

• RCD tests

  Select Push button test Trip time 0 degree Trip time 180 degree Trip current

  • Push button test
  • Trip time 0 degree
  • Trip time 180 degree
  • Trip current

• RCD operated when test button pushed

  Yes

  No

• RCD trip time

• RCD trip time

• RCD trip value

• Would you expect the RCD to have operated at the time of the incident

  Yes

  No

Site tests

Voltage between points of contact

• Points of contact were:

• Test result

• Measured between:

Independent earth voltage tests

• Test result

• Measured between independent earth and:

Earth continuity tests

• Test result

• Measured between:

Fault loop impedance tests

• Test result

• Measured at:

Insulation resistance tests

• Test result

• Measured between:

• Measured at

Network analyser tests

• Measured at

• Voltage line to neutral

• Voltage line to earth

• Impedance line to earth

• Impedance line neutral

• RCD tests

RCD tests

• Indicate which RCD was tested

• Tests undertaken

  Select Push button test Trip time 0 degree Trip time 180 degree Trip current

  • Push button test
  • Trip time 0 degree
  • Trip time 180 degree
  • Trip current

• Did RCD trip when test button pushed

• 0 degree trip time

• 180 degree trip time

• Trip current

• Other tests

other tests

• Details of other tests including type of test, results and test points

• Photos of scene:

  Media

• Observations made/description of events.

• Comments made by person(s)

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

Physical evidence collected from site:

• Items collected to support findings:

• Additional Information:

• Further actions taken by me were:

• Conclusion:

  No defects found within electrical installation, on electricity network, electrical appliances or electrical equipment

  Fault found on distribution asset

  Fault found on electrical installation

  Faulty/defective appliance or electrical equipment

  Static shock

• A fault was found on a distribution asset which was:

• Defects were found at the installation which were

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

• An inspection of the installation discovered an issue with an electrical appliance or piece of electrical equipment which was:

• I believe the cause of the shocks was static electricity due to these facts:

• Defect notice issued

  Yes

  No

• DEI Number

• Description of defects

• 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