VISY HSE Incident Investigation Report

• Site

• Division

• Short Description of the Incident , date and time

• Date of investigation

  Date

• Investigation team

• Location
  Address

• Comments , make note if the investigation is subject to legal privilege

• Sign off by principle investigator

  Sign

• Use this form to investigate any environmental of safety incident requiring a detailed understanding of root causes and corrective actions .
  The form is constructed in section as a structured process to answer the above questions.
  
  The investigation of an incident should involve a team with knowledge of the plant , the process and HSE systems and investigations.
  
  On completion circulate the form to relevant supervisors and managers and file it with the incident details on the incident management system.
  
  Corrective actions must be detailed in the incident management system once approved and responsibilities and timelines assigned.

Incident Description

• Type of Incident/Investigation

  Select LTI MTI AI ( Work Injury) Near Miss Audit Hazard Investigation Environmental Incident Plant/Property Damage Other

  • LTI
  • MTI
  • AI ( Work Injury)
  • Near Miss
  • Audit
  • Hazard Investigation
  • Environmental Incident
  • Plant/Property Damage
  • Other

• Rate the scale of the incident against the Visy severity score table

  Level 5

  Level 4

  Level 3

  Level 2

  Level 1

• Did and Injury Occur?

  Yes

  No

• Detailed description of the injury or incident

Event Description

• Pre-Event Description

• Main Event Description

• Post Event Description

• PHOTOGRAPHY AND DETAILS

• Provide photographs of the incident scene

  Media

• Provide photographs of any off site impacts

  Media

• Sketch the incident scene

  Drawing

• Names of any witnesses

• Statements or information provided by witnesses

• Were external notification procedures followed and adequate?

  Yes

  No

Cause and failure analysis (Refer to Visy Severity Rating System)

• Was Machinery a likely cause of the incident . If so provide details<br>Consider<br>Instructions, Signage , Safety switches, Guarding, Training, Walkways and markings, Lighting, Tools

  Yes

  No

• How did this influence the incident?

  major cause

  Secondary cause

  Contributing factor

• Was a failure with PPE a likely cause of the incident?<br>Consider<br>Usage, Availability, Appropriateness, Condition, Maintenance, Storage, Training.

  Yes

  No

• How did this influence the incident?

  major cause

  Secondary cause

  Contributing factor

• Was housekeeping a likely cause of the incident?<br>Consider<br>Floors, passageways, work surfaces, lighting, ventilation, storage, waste accumulation .

  Yes

  No

• How did this influence the incident?

  major cause

  Secondary cause

  Contributing factor

• Is chemical handling a likely cause of the incident?<br>Consider<br>Storage, instructions, signage, labelling, safety date sheets., training.

  Yes

  No

• How did this influence the incident?

  major cause

  Secondary cause

  Contributing factor

• In this an environmental management failure?<br>Consider <br>Spills and leaks, maintenance, stormwater protection and planning, emissions, waste and trade waste, third party and contractor considerations.

  Yes

  No

• How did this influence the incident?

  major cause

  Secondary cause

  Contributing factor

• Other?

  Yes

  No

• ROOT CAUSE

• Identify the root cause below.
  Make use of the 5 why technique , brainstorm ideas , consider which factor if removed would have prevented the incident from occurring. Review corrective actions for this root cause to ensure they would prevent the incident.

• CORRECTIVE ACTIONS

• Apply the hierarchy of Control to reduce future risks from this sort of incident based on the identified root cause.

• Can the risk be eliminated ? If so descrbe-

  Yes

  No

• Who is responsible for taking action and the due date?

• Can processes or new materials be substituted for current practices so that the risk is reduced or eliminated?<br>If so describe-

  Yes

  No

• Who is responsible for these actions and when will the actions be completed?

• Can engineering controls be implemented to reduce or eliminate the risk?<br>If so please describe-

  Yes

  No

• Who is responsible for the actions and when should they be completef?

• What procedural or admin controls, if any, can be implemented to reduce or eliminate the risk of reoccurrence ?<br>Describe -

  Yes

  No

• Who is responsible for developing these admin controls and when do they need to be finalisedf?

• Is PPE needed due to the limited effectiveness of other controls to ensure the risk of injury is reduced or eliminated ?

  Yes

  No

• Who is responsible for this action and what is the time frame?

• Any other notes on controls and responses?

  Yes

  No

  N/A