MAD Incident Reporting and Investigation 1. Purpose The purpose of this procedure is to define a method for the reporting, investigation and implementation of corrective actions following an incident. 2. Scope This procedure applies to work related hazards or incidents that result, or could have resulted, in injury or environmental damage. Incidents that relate to psycho-social impacts (e.g. occupational violence, verbal assault) at a worksite are included in the scope of this procedure. Privacy 1 P age
considerations shall be particularly taken into account for these types of incidents and the HR Committee Chair (Manager) may also be involved in investigating these incidents. Bullying incidents that involve MAD employees only are not included in the scope of this procedure and shall be managed using GCHR202 Workplace Bullying and Violence Prevention. 3. Related Documents Australian Standard 1885.1-1990Measurement of occupational health and safety performance -Describing and reporting occupational injuries and disease (known as the National Standard for workplace injury and disease recording) GCWHSE201 -Risk Management GCWHSE202.1 Legislation Register GCWHSE203 -Planning, Review & Monitoring 4. Definitions Hazard Near Miss Accident Incident Notifiable Incident A situation or object that has the potential to cause harm to people, property or the environment. unplanned event which although not resulting in harm, had the potential to cause harm to people, property or the environment. An event, usually resulting in injury, which occurs unexpectedly and unintentionally. An event, possibly resulting in damage to people, property or the environment that could have been prevented. For the purpose of this procedure, incident is the generic term used to refer to an event that could have or did result in damage to property, environment or injury to persons (i.e. near miss, incident or accident). A notifiable incident is defined as an incident or dangerous occurrence as outlined in workplace health and safety (WHS) legislation that is required to be notified to the state/territory WHS Authority 5. Responsibilities Board of Trustee Group project Managing Director and President Sub Committee Chair (or equivalent) Team/ Group Managers/ Project Managers Monitor via board reports that incident and trend analysis corrective actions are implemented and effective Immediately report notifiable incidents to the relevant state / territory WHS Authority. Consult with WHSE Manager if uncertain that incident is notifiable. Determine incident reporting communication lines within their region Check corrective actions are implemented and effective Familiarise team members with incident reporting requirements as defined in this procedure and actively encourage reporting 2 P age
Undertake investigations and implement corrective actions as required by this procedure Employees and other workers WHSE Manager Report incidents and near misses within timeframes Participate in investigations and implementing corrective actions Assist with incident reporting, investigations and selection of corrective actions Include incident information in Board reports, based on information provided by Regions Distribute incident summaries to enhance WHSE awareness and sharing of learnings Periodically analyse incident trends 6. Procedure 6.1 Reporting All incidents including accidents, near misses and hazards are to be reported. Personal details will be recorded on incident forms however shall not be included in distributed lists of incidents and corrective actions. The project manager is to be notified verbally immediately after the event has occurred. Where the project manager is not available, the team manager is to be notified. The employee is then required to complete a GCWHSE307.1 Incident / Hazard Report and Investigation Form within one working day of return to the office or earlier if they have internet access. An Incident Register shall be maintained by the WHSE Manager and records may also be kept locally in each region. Regional Directors (or equivalents) shall arrange for provision of incident information to the WHSE Manager for inclusion in monthly Board reports. Incidents will also be reported to the client or client site representative in accordance with agreed procedures specified by the client. Incident reporting may be required on the same work day on which the incident occurs. Reporting Certain Incidents to the Board of Trustee Group Managing Director Notifiable incidents must be reported to the Board of Trustee Group Managing Director within 2 hours and work related medical treatment incidents within 48 hours. The WHSE Manager shall also be advised as soon as practicable. Other incidents shall be reported via monthly Board reports compiled by the WHSE Manager from information provided by each region. Each Trustee (or equivalent) shall determine reporting lines within their region to meet these timeframes. 6.2 Notification of Incidents to Regulatory Authorities Work Health and Safety Under the relevant state / territory work health and safety legislation, certain incidents and dangerous occurrences are required to be notified to the government WHS Authority refer GCHWSE307.2 State / Territory Notifiable Incident Information. As a guide ONLY, reportable incidents generally include: Fatalities Work related incidents that result in being admitted to hospital Fractures, amputations, degloving, descalping and serious lacerations Certain diseases Near misses relating to structural collapse, falls from height, electrocution, spills 3 P age
Environment Certain environmental incidents (e.g. major spills, contravention of licence) must be reported to the relevant state / territory environment authority. Refer GCWHSE307.2 State / Territory Notifiable Incident Information. If a Notifiable Incident occurs, the Team Manager of the employee or other worker involved in the incident must immediately advise the Board of Trustee who must notify the relevant WHSE Authority. This must be in the form of verbal notification immediately following the event and written notification on the form prescribed by the Authority within 48 hours of the event. Details of notification shall be recorded on GCWHSE307.1 Incident / Hazard Report and Investigation Form. Incidents at Community Sites If the incident occurs on a community site, the project manager must liaise with the client to determine how reporting is to occur. It should NOT be assumed that the Council will report the incident. Note at school there may be requirements for the Principal to report incidents. Site Preservation The site of a notifiable incident must not be disturbed until an inspector arrives or directs otherwise at the time of notification, although the site may be disturbed to protect a person's health or safety, to help someone who is injured or to make the site safe. 6.3 Incident Investigation The primary aim of an incident investigation is to prevent re-occurrence. All incidents and hazards are to be investigated using GCWHSE307.1 Incident / Hazard Reporting& Investigation Form. The investigation shall examine relevant system related issues and broader implications as well as the specifics of the incident. WHSE representatives and / or committees shall be consulted regarding incident investigations and corrective actions. 6.3.1 Investigation Team Accident, incident and near miss investigations will be conducted by the employee involved, with the assistance of the Board of Trustees, Project Manager, Team Manager and/or Group Manager and the WHSE Manager or WHSE Committee where required. The level of investigation undertaken will be determined in response to the Actual Consequence and Maximum Reasonable Outcome for each accident, incident or near miss as outlined below. Actual Consequence Maximum Reasonable Consequence Investigation Team Required First aid or medical treatment $0-$5k damage/loss Short term environmental impact managed on-site. First Aid, medical treatment, lost time/restricted work duties $0-$500k damage/loss As above + medium term on-site impact needing external assistance. Lost time/ restricted work duties, fatality or severe permanent disability First Aid or Medical Treatment $0-$5k damage/loss Short term environmental impact managed on-site. Lost time or restricted work duties $0-$500k damage/loss Medium term on-site environmental impact needing external assistance. Multiple fatalities / health effects to >50 people >$5M Team member & Project Manager, President Team member, Project Manager & Board Group/Team Manager & President Team member, Project Manager & Group/Team Manager, WHSE Committee, President (or 4 P age
$0-$5M As above + off-site impact. Very serious, long-term environment impairment of ecosystem functions. Mulitple fatalities / Health effects to >50 people >$5M As above + most serious, irreversible environment impairment of ecosystem functions. Most serious, irreversible environment impairment of ecosystem functions. Mulitple fatalities / health effects to >50 people >$5M Most serious, irreversible environment impairment of ecosystem functions. equivalent) President,Team member, Project Manager & Group/team Manager, WHSE Manager, Regional Director (such as Council, Principal or equivalent), Regulator 6.3.2 Investigation Process Fact Gathering: Identify exactly what happened by talking to witnesses separately. Visit the incident site if practicable or use maps/photos. Establish sequence of events Separate facts from supposition Establish exactly what should have happened Collect documents to support the findings (e.g. photos, safe work instructions) Identify Incident Cause: Analyse the differences between what actually happened and what should have happened to develop a list of causes. Analyse incidents in terms of systems, procedures, equipment/tools and working environment. Look for system related incident causes, particularly in relation to actions of people. Keep asking why. For example, if a person did not follow a procedure did they know it existed, was the procedure inappropriate, was the person trained, was there a culture where the procedure was not followed, were there time impacts, etc. 6.4 Corrective Actions Corrective actions shall be identified by analysing each cause. Corrective actions must be included for broader system deficiencies. Consultation must occur when developing corrective actions to ensure they are practical and there is ownership of the solution. Corrective actions shall be based on the hierarchy of control: 1. Eliminate the hazard (e.g. dispose of trip hazard) 2. Substitution (e.g. use less toxic chemicals) 3. Isolation (e.g. barrier) 4. Engineering controls (e.g. guarding, ventilation, lifting devices) 5. Administrative controls (e.g. work hours, training, signs, procedures) 6. Personal protective equipment (PPE) and clothing. On occasions, a combination of risk control measures is appropriate to eliminate or reduce the risk (e.g. safer chemical used however PPE still required). On other occasions, a lower order control may be put in place until a more permanent control is implemented (e.g. place barrier around spill in short term then fix leaky roof). The investigation shall be documented on GCWHSE307.1Incident / Hazard Report & Investigation Form and forwarded to all relevant parties, including regulatory bodies where required. Responsibility for carrying out corrective actions and an appropriate time frame shall be determined. Completion of actions shall be documented either via the 5 P age
GCWHSE307.1 Incident / Hazard Report & Investigation Form or a Corrective Action Register or similar. Tracking of completion of corrective actions is ultimately the responsibility of the Vice President (or equivalent) however this function may be delegated (e.g. to regular Committee Managers Meeting and/or WHSE Committee). 6.5 Effectiveness of Corrective Actions Corrective actions shall be monitored in order to determine whether the control: Continues to be implemented (e.g. speed limits are actually observed or guards are not damaged) Is effective (e.g. trolley provided as a solution to manual handling task may be inappropriate for the task) Does not introduce unforeseen hazards (e.g. road speed sign may reduce visibility at a corner). An appropriate follow up time shall be determined to ensure that corrective actions are adequate and appropriate. The person responsible for carrying out this review shall be noted at the time corrective actions are determined. Note corrective actions may be checked as part of existing checks(e.g. periodic inspections, training refreshers). 6.6 Identification of Incident Trends A twice annual review of the incidents that have occurred during the previous 6 months will be undertaken by the WHSE Manager, with the intention of identifying any trends. The WHSE Committee in each region may also undertake trend analysis. Factors to consider include: Type of task Type of work location Weather or other environmental factors Season Time of day Day of week Time in shift Equipment involved This information will be used to formulate additional corrective actions and also be an input into WHSE planning. 6.7 Distributing Relevant Incident Information To encourage further reporting and to enhance the opportunity for all to learn from incidents, the WHSE Manager shall prepare and distribute information on incidents that have occurred and corrective actions. Names of persons involved in incidents shall not be included and privacy considerations shall be respected. 6.8 Reporting to clients Where required, MAD will follow any client or funding body procedures for the reporting and investigation of incidents. Where appropriate, funding bodies and clients will be notified of the details and outcomes of incidents and any associated investigations. 6 P age