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Injury / Incident

Investigation

CAA HSU INFO 5.3 Rev 02: 08/09

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______________________________________

Contents

Flowcharts

Injury/Incident

Investigation

Forms

Injury/Incident

Form

Investigation

Form

Serious Harm Notification Form

Definitions

Serious Harm

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Injury/Incident Flowchart

Employee reports an injury or incident

If Serious Harm (see definition)

notify CAA or DoL to give advice of the event; Phone

or fax

Use the Investigation Form

Investigate to find out what caused and contributed to the injury or incident.

Complete the Injury/Incident Form INJURY

Ensure they get appropriate first aid and / or treatment,

and ensure the safety of others.

INCIDENT

Complete Serious Harm Notification Form and

send

Serious

Minor

Feed results back to employee

Action health and safety issues identified.

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INVESTIGATION FLOWCHART

END

Report or feedback to Manager, Injured person,

H&S committee etc Begin the investigation into the

injury/incident. Use the Investigation Form

Collect information and ask open-ended questions

Consider the factors contributing to the injury/incident. Describe

what key factors were involved.

Write down what needs to be done to avoid a repeat of the situation

• Who will do it

• When will it be done

START

Effective investigation can help you develop controls, define trends and find ways to prevent similar events from happening.

Make sketches, maps, take photos, conduct interviews. Examine equipment. Check records

• Training records

What, when, how, where, who, why ...?

• Job procedures, practices

• Maintenance

logs/records Was it...

The task, including people factors

The system, environment, equipment

The culture (how we do things here, e.g. Processes, decisions)

Do you need to ....

Review hazards and their controls

• Guarding

• Maintenance

• Work practices

• Training

• PPE

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INJURY/INCIDENT FORM

___________________________________________________________________ ______________________________________ _

INCIDENT DETAILS

Incident type: Near Miss † Injury † Illness †

Severity: † Minor (First Aid) † Moderate (1 to 4 days off work) † Potentially Serious † Serious (see Serious Harm definition) † Unknown

What Happened?

What do you think caused or contributed to the incident?

Personal Details

Name: __________________________________ Date of Birth: ____________________________ M /F Phone: ______________________ Date and Time of Incident:____________________/________________

Injury Details

Body Part: Injury Type: (Tick)

Shade the part of the body that is injured

†Ache/pain (gradual)

†Ache/pain (sudden)

†Amputation

†Broken Bone

†Bruising incl crushing

†Burns/scalds

†Chemical reaction

†Choking/suffocation

†Concussion/brain injury

†Cut (infected)

†Cut (not infected)

†Dental injury

†Dermatitis

†Dislocation

†Fatal

†Foreign Body (eye, ear, nose)

†Inhalation disease (asbestos/lead)

†Hearing Loss (noise induced)

†Poisoning

†Strain/Sprain

†Other:_____________________________

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INVESTIGATION FORM

________________________________________________

Health and Safety Investigation Details

Short title / description of injury/incident:

Information Details

Describe what information you have collected about the injury/incident:

(who is injured, witnesses, interviews, observations, photos, notes, re-enactments.)

Analysis

Describe what key factors/hazards contributed to the injury/incident:

(Consider tasks, people factors, systems, environmental factors, equipment, culture, weather, etc.)

Action Details

Describe what needs to be auctioned to fix the situation:

(What changes will be made, who approves them, who needs to be informed about them.)

Action Plan Assigned to:___________________________________ Date Action Due:_____________________________

Action Completed:____________________________

Does the Hazard Register need updating? Y / N Updated On: __________________________ REPORTING DETAILS:

Has CAA / DoL been advised? Y / N Date Advised: _________________________

______________________________________________________________________________________________________________________________________ Sig: _________________________ Title: _________________________________________________________

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Form of register or notification of circumstances of accident or serious harm

Required for section 25(1), (1A), (1B), and (3)(b) of the Health and Safety in Employment Act 1992 For non-injury accident, complete questions 1, 2, 3, 9, 10, 11, 14 and 15 as applicable

11 Agency of accident/ serious harm: 1 Particulars of employer, self-employed person or principal:

(business name, postal address and telephone number) † machinery or (mainly) fixed plant † mobile plant or transport

† powered equipment, tool, or appliance

† non-powered handtool, appliance, or equipment † chemical or chemical product

2 The person reporting is: † material or substance

† an employer † a principal † a self-employed person † environmental exposure (e.g. dust, gas)

† animal, human or biological agency (other than bacteria or virus) 3 Location of place of work: † bacteria or virus

12 Body part:

† head † neck † trunk

† upper limb † lower limb † multiple locations † systemic internal organs

(shop, shed, unit nos., floor, building, street nos. and names,

locality/suburb, or details of vehicle, ship or aircraft) 13 Nature of injury or disease: † fatal 4 Personal data of injured person: (specify all)

† fracture of spine † puncture wound Name

Residential address † other fracture † dislocation † poisoning or toxic effects † multiple injuries † sprain or strain † damage to artificial aid † head injury † disease, nervous system Date of birth Sex (M/F) † internal injury of trunk † disease, musculoskeletal system

† amputation, including eye † disease, skin 5 Occupation or job title of injured person:

(employees and self-employed persons only) † open wound † superficial injury † disease, digestive system † disease, infectious or parasitic † bruising or crushing † disease, respiratory system † foreign body † disease, circulatory system

† burns † tumour (malignant or benign)

6 The injured person is:

† nerves or spinal chord † mental disorder † an employee † a contractor (self-employed person)

† self † other

14 Where and how did the accident/serious harm happen? (If not enough room attach separate sheet or sheets.)

7 Period of employment of injured person: (employees only)

† 1st week † 1st month † 1-6 months

† 6 months-1 year † 1-5 years † Over 5 years † non-employee

8 Treatment of injury:

† None † First aid only

† Doctor but no hospitalisation † Hospitalisation 9 Time and date of accident/ serious harm:

Time am/pm

Date Shift † Day † Afternoon † Night

15 If notification is from an employer:

(a) Has an investigation been carried out? † yes † no (b) Was a significant hazard involved? † yes † no

10 Mechanism of accident/ serious harm:

† fall, trip or slip † hitting objects with part of the body † sound or pressure † being hit by moving objects † body stressing † heat, radiation or energy † biological factors † chemicals or other substances † mental stress

Signature and date ________________________ ___ / ___ / ___ Name and

position

(capitals) Hours worked since arrival at work

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Serious harm: Definition

Serious harm is defined in the Act as death or harm of any of the following kinds:

1) Any of the following conditions that amounts to, or results in, permanent loss of bodily function or temporary severe loss of bodily function:

respiratory disease; noise-induced hearing loss; neurological disease; cancer;

dermatological disease; communicable disease; musculo-skeletal disease;

illness caused by exposure to infected material; decompression sickness;

poisoning;

vision impairment;

chemical or hot metal burns of eye; penetrating wound of eye;

bone fracture; laceration; crushing.

2) Amputation of a body part.

3) Burns requiring referral to a specialist registered medical practitioner or specialist outpatient clinic. 4) Loss of consciousness from lack of oxygen.

5) Loss of consciousness or acute illness from absorption, inhalation or ingestion of any substance, requiring treatment by a registered medical practitioner.

6) Any harm that causes the person to be hospitalised for 48 hours or more, commencing within 7 days of the harm's occurrence.

Temporary Severe Loss

of Bodily Function

Overall the judgement on whether an employee has suffered temporary severe loss of bodily function is determined by whether there has been an actual loss of bodily function, and this will involve the employer (or representative) making a judgement.

Those who need to determine if temporary severe loss has occurred will need to answer the following questions:

• Is the employee suffering from pain or health impairment which is significantly more than

discomfort?

• Is the pain or health impairment severe enough to prevent an employee using part of the

body, i.e. movement prohibited by pain, respiratory distress, etc?

• Is the employees condition likely to be temporary?

If the answer to these three questions is ‘Yes’, then the event should be notified in terms of Section 25 of the Act.

References

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