Audit

TLL Initial Incident - Hazard Report

Incident reported by

Date & time of incident
Location of incident
Actual and potential consequence of incident

Actual consequence of incident

Potential consequence of incident

Product(s) involved?

Fuel or bitumen involved in incident?

Select products involved
Incident type

Complaint or compliment

Select complaint or compliment

Provide detaills

Environmental

Product release was to
Estimate volume released (litres)

Was the site closed because of the product release?

How long was the site closed for?

Equipment damage

Damage was to
Only if safe - photo of damage

Equipment failure

Equipment failure was to

Hazard

Provide details of the hazard

Only if safe - photo of hazard

Injury or work related illness

The injury or illness resulted in

Procedure or administration issue

Provide details of procedural of administrative issues

Product contamination

Product contamination was from

Product overfill

Volume of overfill (litres)

Stock outage

Time site ran out of fuel
Time to make delivery on-site (hours)

Near miss

Vehicle accident

Speed of vehicle

Third party vehicle involved?

Registration number of third party

Name and contact details of driver

Details of any witnesses

Only if safe - photo of vehicle damage
Incident details

Summary of event

Was weather a contributing factor?

Enter weather conditions

Agencies involved or contacted in relation to the incident

Were emergency services or a regulatory authority involved in the incident response?

Fire brigade

Ambulance

Police

WorkSafe

Council

Other (detail)

Corrective actions

Provide brief summary of any immediate corrective action(s) taken

When the report is complete, forward a copy to your manager.

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.