General Medium Potential Incident Investigation Form

Reporting department:

Date of incident:

Time of incident:
Incident location:
Incident severity

Activity controlled:
(0, 1, 2, 3, 4 or 5) :

] injury

] occupational illness

] environmental

] asset damage

] reputational

] Potential risk rating

[ ]

] PDO

] Contractor

] Third party

Activity at the time of the incident

Broad description of the incident

(See App 6b for guidance)

(See App 6c for guidance)

[ ] Using portable tools or equipment

[ ] Slips/trips/falls (same level)

[ ] Welding / burning

[ ] Fall from height

[ ] Manual lifting / handling

[ ] Falling objects

[ ] Cleaning

[ ] Fire or explosion

[ ] Operating plant / machinery

[ ] Electrocution/electrical

[ ] Digging

[ ] Struck by

[ ] Handling hazardous materials

[ ] Struck against

[ ] Sampling

[ ] Crushed by

[ ] Dismantling / assembling

[ ] Trapped against

[ ] Draining / flushing

[ ] Asphyxiation/chemical exposure

[ ] Drilling

[ ] Assault

[ ] Disconnecting

[ ] Loss of containment

[ ] Climbing / descending

[ ] Pollution

[ ] Connections

[ ] Theft or sabotage

[ ] Walking at same level

[ ] Unsafe act or condition

[ ] Diving

[ ] Other:

[ ] Working at height >2m

[ ] Piloting
[ ] Other:

Parties involved
PDO Department/section:

PDO Custodian :

Contractor - subcontractor:

Contract Number:

Third party Name:

Total number injured

How did the incident occur?

(Attach sketch / photographs / event tree as appropriate - more paper may be used if required).
Is the activity and associated hazard/controls addressed in the applicable safety case(s)
If 'No', state measures proposed to rectify :
What actions were taken to determine if alcohol or drug use contributed to the incident?
Immediate action taken to prevent incident happening again

Details of the injured people (in liaison with medical team) (See App 6g for guidance)
Name:
Date of birth:
Employer:
Employee Number:
Job title:
Training attended:
Time on shift before the incident:
Days into rotation/days of rotation:
Previous incidents involving IP:
Date joined company?
Experience in current role?
Injury classification: (if RWC state alternate work assigned)
Nature of the injury or illness:
Part of the body injured:
Est. return to work date:

(if LTI)

[Y/N}? [ ]

Details of the non injured person involved in causation of the incident

Name:
Date of birth:
Employer:
Employee Number:
Job title:
Training attended:
Time on shift before the incident:
Days into rotation/days of rotation:
Previous incidents involving IP:
Date joined company?
Experience in current role?

Cost incurred as a result of this incident (US$) :

PROPERTY DAMAGE:

PRODUCT LOSSES :

Environmental impact : (YES/NO)

Description of impact :

Details of equipment involved: ((See App 6f for guidance)

Type of facility :

Equipment part :

Type of plant/equipment :

Equipment tag No :

Phase of operation :
Details of leaking equipment
Item leaking

Hazardous? (Y/N)

Duration of leak (min) [

Initial pressure (KPa)

Leak area (M2)

How leak stopped? (AUTO / MANUAL)

Final pressure (KPa) [

Did detection system operate? (Y/N)

Name the reason for any detection failure :

Fire or explosion
Duration (Minutes)

How extinguished (Auto/manual)

Extinguishing medium [

Did detection operate? (Y/N)

Name the reason for any detection failure :

Immediate cause
(See App 6d for guidance)

Underlying cause
(see App 6e for guidance)

[ ] Information error or omission

[ ] Incompatible goals

[ ] Influence of intoxicating substances

[ ] Error enforcing conditions

[ ] Failure to follow rules / procedures;

[ ] Training

[ ] Inadequate equipment / tools

[ ] Communication

specify :-

[ ] Procedures

[ ] Misuse of equipment / tools

[ ] Organisation

[ ] Procedure not documented

[ ] Housekeeping

[ ] Work environment

[ ] Maintenance management

[ ] Procedure considered impractical

[ ] Hardware

[ ] Poor housekeeping

[ ] Design

[ ] Procedure not communicated

[ ] Defences

[ ] Access
[ ] Other
[ ] External factors, 3rd party, weather
[ ] Inadequate warning, safety devices
[ ] Other:
[ ] Failure to observe / use warning safety devices
[ ] Lack of due care and attention
[ ] Improper manual handling
[ ] Attack by animal
[ ] Inadequate PPE
[ ] Fatigue / stress
[ ] Failure to wear PPE
[ ] Lack of safety awareness
[ ] None of the above, specify:____________________________

Action taken to prevent recurrence

ITEM

Corrective action

NO.

Action
party

Report writers name:

Target
date

Status

Ref Ind.
SIGNED:

Report writer Supervisors name:

Ref Ind.
SIGNED:

PDO Incident Owners name

Ref Ind.
SIGNED :

Date report completed :

Further recommendations
Date of incident :

Incident description:

Number

Description of recommendation

Action party

Due by

Signature of report writer :