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HSE Incident Management Procedure

Document Number: HSE-PR-080-02

Document Owner: Group HSEQ National Manager

Revision Date: 29 January 2019

Revision Number: 4

BMS Doc No: HSE-PR-080-02 | Rev 4 | Rev Date: 29/01/2019 of 29

Contents

Definitions and Abbreviations 4Referenced Documents Listing 5Purpose 6Scope 61. Incident Classification and Inclusions / Examples 72. Responsibilities 16

2.1 Senior Management 162.2 Regional and Operations Managers 162.3 Group HSEQ & Regional HSEQ 162.4 Workplace Manager 162.5 Workplace HSE Personnel or Delegate (i.e. Supervisor / Engineer) 172.6 Employees and Subcontractors 172.7 Health and Safety Representatives 17

3. Procedure 183.1 Reporting of Incidents 183.2 Immediate Action Post Incident 183.3 Classification of Incidents 183.4 Actual / Potential Incident Classifications and Escalation 193.5 Reviewing Initial Incident Reports 203.6 Investigating an Incident 213.6.1 Investigation Teams 21

3.6.2 Interviewing a Witness 22

4. HSE Incident Report 234.1.1 Determine the Sequence of Events 23

4.1.2 Determine Causal Factors 23

4.1.3 Identify Root Causes 23

4.1.4 Develop Corrective Actions 23

4.1.5 Incident Investigation Report Review and Approval 24

4.1.6 Issue Resolution 24

5. CALCULATION OF HPIFR, TRIFR AND AIFR 25


5.1 To calculate HPIFR, use the following formula: 255.2 To calculate TRIFR, use the following formula: 255.3 To calculate AIFR, use the following formula: 25

6. Workers Compensation and Injury Management 257. Legal Professional Privilege 258. Communication 26

8.1 Incident Debrief 26

9. Statutory and/or Third-Party Reporting Requirements 2610. Training 27Appendix A - Establishing the Facts – Questions to Ask 28

Revision History

Rev No Date Revision Details Approved by

01 28/06/2017 Template update National Group HSEQ Manager

02 25/05/2017 TRIFR definition amended National Group HSEQ Manager

03 08/03/2018 Inclusion of Decmil subsidiaries requirements and template updated.

National Group HSEQ Manager

04 29/01/2018 Inclusion of EGM Role, change of corporate role to regional role.

National Group HSEQ Manager


Definitions and AbbreviationsAIFR All Injury Frequency Rate.BMS Business Management System.CMO Compliance Management Organisation Software.Consequence Management

Apply appropriate consequences in relation to the incident that has occurred if required. For example, if agreed procedures and processes are not complied with, a review shall be undertaken to determine if motivation or ability is a factor and if coaching, redirection, or performance management is required to deliver HSE Compliance.

Decmil / Company Inclusive of all Decmil Group Subsidiaries.DecNet Decmil Intranet Website.EGM Executive General Manager

Environmental Incident

An event that causes, has caused, or has the potential to cause environmental harm or pollution that exceeds regulatory limits. These incidents include but are not limited to the following:▪ Implosion, explosion or fire; ▪ Escape, spillage or leakage of hazardous or toxic substances

(including dangerous goods); ▪ Discovery of contaminated materials such as asbestos, low-level or

prescribed wastes, etc.; ▪ Contamination of natural waterways (streams, creeks, rivers, etc.) or

public drains; ▪ Failure of soil erosion and sedimentation control structures; ▪ Excessive / harmful air emissions (dust, smoke, fumes, etc.); ▪ Excessive / harmful noise or vibration; ▪ Damage or destruction of classified cultural heritage materials / sites;

and▪ Damage or destruction of specified or protected flora / fauna.

ERT Emergency Response Team.FAI First Aid Injury.Hazard A source of potential harm, or a situation with the potential to cause loss

or harm in terms of people, environment, assets or a combination of these.

HPIFR High-Potential Incident Frequency Rate.HSE Health, Safety and Environment.HSEQ Healthy, Safety, Environment and Quality.HSEMS Health, Safety and Environmental Management System.Incident Type ▪ High Potential Incident (HPI).

▪ Dangerous Incident.▪ Personal Injury:

▪ Fatality.▪ Lost Time Injury.▪ Permanent Disability.▪ Restricted Work Injury.▪ Medical Treatment Injury.▪ First Aid Injury.▪ Minor Injury – No Treatment.

▪ Near Miss (Close-Call).▪ Property Damage.▪ Procedural Breach.▪ Security Event.▪ Non-Work Related.▪ Environmental incidents classified as follows:


▪ Environmental – Catastrophic.▪ Environmental – Major.▪ Environmental – Moderate.▪ Environmental – Minor.▪ Environmental – Insignificant.

JHA Job Hazard Analysis.LTI Lost Time Injury.MTI Medical Treatment Injury.OFSC Office of the Federal Safety Commissioner.Root Cause Analysis The search for the best practices and/or missing knowledge that will keep

a problem from recurring.Root Cause The absence of a best practice or the failure to apply knowledge that

would have prevented the problem.RWI Restricted Work Injury.Safety Foundations Decmil’s ‘Safety Foundations’ are mandatory and must be in place before

the activities covered by these rules can proceed. They do not cover all operational risks, nor do they replace Decmil risk management processes. These ‘Safety Foundations’ cover the following activities:▪ Works at Height.▪ Excavations.▪ Hand and Power Tool Use.▪ Plant and Vehicle Operations.▪ Isolations and Commissioning.

Safety Incident An unplanned event resulting in or having a potential for injury, ill health, damage or other loss.

Shall The word is understood to be mandatory.Should The word is understood as recommended but not mandatory.SMARTER Specific, Measurable, Accountable, Reasonable, Timely, Effective,

Reviewed.SWMS Safe Work Method Statement.Taproot Root cause analysis system used for incident investigations.TRIFR Total Recordable Injury Frequency Rate.

Referenced Documents ListingEM-PR-040 Crisis, Emergency Management and Business Continuity Management

SystemHSE-GL-010-002 Safety FoundationsHSE-GL-030-001 Legal and Other Requirements RegisterHSE-PR-030 HSE Legal Obligations and Other Requirements ProcedureHSE-PR-040 Hazard Identification and Risk Management ProcedureHSE-PR-070 HSE Consultation and CommunicationHSE-SWP-090-01 Workers Compensation and Injury Management ProcedureHSE-TP-040-011 Workplace Risk Assessment TemplateHSE-TP-070-005 HSE Alert TemplateHSE-TP-080-02-001 HSE Witness Statement HSE-TP-080-02-002 Incident Investigation ChecklistHSE-TP-080-02-003 Incident Interview Record


HSE-TP-080-02-004 Taproot Investigation Report TemplateHSE-TP-080-02-005 Taproot Snap Chart Template

For all legal and other requirements refer to the Legal and Other Requirements Register (HSE-GL-030-001), Workplace Safety Australia and Australian Standards Online within the BMS on DECNET.

PurposeThis procedure provides guidelines to ensure that safety and environmental incidents are appropriately reported, investigated and managed, to ascertain the root cause of the incident, and to develop corrective actions to prevent recurrence.

It also outlines the requirements for statutory reporting of notifiable work-related injuries, dangerous incidents and/or critical incidents to the applicable Country, Federal, State or Territory Authority and to the Australian Office of the Federal Safety Commissioner (OFSC) or other applicable certification bodies.

ScopeThis procedure applies to all Decmil Group and subsidiary companies, workplaces and employees.


1. Incident Classification and Inclusions / ExamplesTable 1

Type Definition Inclusions / Examples

Critical Incident Is ‘a traumatic event, or the threat of such which causes extreme stress, fear or injury’ to workers (employees).

Critical incidents are not limited to, but could include:

▪ Serious injury, illness, or the death of a worker; or

▪ Major long-term impact to the environment.

High Potential Incident (HPI) An incident not causing loss or damage, but under different circumstances could have resulted in significant loss or damage. This is determined by completing an assessment of the risks presented during an investigation. (Refer to HSE-PR-040 Hazard Identification and Risk Management Procedure).


Type Definition Inclusions / Examples

Dangerous Incident An incident in relation to a workplace that exposes a worker or any other person to a serious risk to a person’s health or safety emanating from an immediate or imminent exposure to:

▪ An uncontrolled escape, spillage or leakage of a substance; or

▪ An uncontrolled implosion, explosion or fire; or

▪ An uncontrolled escape of gas or steam; or

▪ An uncontrolled escape of a pressurised substance; or

▪ Electric shock; or▪ The fall or release from a height of any

plant, substance or thing; or▪ The collapse, overturning, failure or

malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the regulations; or

▪ The collapse or partial collapse of a structure; or

▪ The collapse or failure of an excavation or of any shoring supporting an excavation; or

▪ The in-rush of water, mud or gas in workings, in an underground excavation or tunnel; or

▪ The interruption of the main system of ventilation in an underground excavation or tunnel; or

▪ Any other event prescribed by applicable statutory legislation.


Type Definition Inclusions / ExamplesNotifiable Incident An incident defined in the relevant Country,

Federal, State or Territory legislation that must be reported to the relevant health and safety authority.

It is generally taken to mean: ▪ The death of a person; or▪ A serious injury or illness of a person; or▪ A dangerous incident.

Serious Injury or Illness ▪ Immediate treatment as an in-patient in a hospital; or▪ Immediate treatment for:

▪ The amputation of any part of his or her body; or▪ A serious head injury; or▪ A serious eye injury; or▪ A serious burn; or▪ The separation of his or her skin from an underlying tissue (such as degloving or

scalping); or▪ A spinal injury; or▪ The loss of a bodily function; or▪ Serious lacerations; or

▪ Medical treatment within 48 hours of exposure to a substance, and includes any other injury or illness prescribed by the relevant regulations.

Fatality ▪ An incident that has resulted in the loss of an employee’s life.


Type Definition Inclusions / ExamplesPermanent Disability Where an employee is injured, and the

injured body part is not able to be physically rehabilitated to 100% of its pre-injury functional capacity.

▪ Loss of the tip of a finger.▪ Spinal fusion.

Lost Time Injury (LTI) Where an employee is unable to work their next or any subsequent, full rostered shift / workday due to a work-related injury. Where an injured employee is absent for a shift / workday because of travel (from regional areas) to enable a medical diagnosis to be obtained, travelling time alone shall not constitute a LTI.

▪ Where certified by a medical practitioner as totally unfit for duties.▪ Where hospitalised for treatment for a full rostered shift / workday.

Restricted Work Injury (RWI)

An injury requiring medical treatment where the treating Medical Practitioner has certified that an injured employee is unable to perform either one or more of their routine work functions or partial shift hours only. Routine work functions are the work activities that the person performs at least once a week.

▪ RWIs shall meet the MTI criteria prior to being considered a RWI.


Type Definition Inclusions / ExamplesMedical Treatment Injury (MTI)

An injury where the level of treatment is restricted to a Medical Practitioner, Medical Professional or licensed Health Professional (on referral by a treating Medical Practitioner). Treatments listed in the MTI table, are considered to be MTIs, regardless of the professional status of the person providing the treatment.

▪ Loss of consciousness.▪ Application of sutures (stitches), staples or other such wound closing

devices. Wound coverings such as bandages, Band- Aids™, gauze pads, butterfly bandages or Steri-Strips™ are considered First Aid.

▪ Removal of foreign body embedded in the eye.▪ Removal of foreign bodies from a wound where procedure is

complicated (i.e. due to depth of wound).▪ Use of prescription medication or prescription strength medication

(except for a single dose administered on the first visit for a minor injury or discomfort).

▪ Three (3) or more interventions by a licensed health care professional (i.e. Physiotherapist, Chiropractor) upon referral of a medical practitioner, where it is not for preventative treatment.

▪ Treatment of second or third-degree burns.▪ Infection of a wound requiring oral or intravenous antibiotic. Oral

antibiotics provided as a precautionary measure only (i.e. no existing infection is to be considered first aid).

▪ Positive diagnostic procedure (i.e. diagnosis of a fracture, abnormal ECG).

▪ Dental treatment as a result of a work injury, excluding superficial treatment such as smoothing or polishing.

▪ Intravenous saline drip for treatment of heat stress.▪ Continued use of oxygen after exposure to toxic or noxious

atmospheres, with the exception of one-off first aid application.▪ Excludes hospital observation where a negative diagnosis has been

established.


Type Definition Inclusions / ExamplesFirst Aid Injury (FAI) A FAI is defined as the level of treatment

normally permitted to be provided by a First Aider and Paramedic.

▪ Application of wound coverings such as bandages, Band-Aids™, gauze pads, butterfly bandages or Steri-Strips™. The application of sutures (stitches), staples or other such wound closing devices are considered Medical Treatment.

▪ Use of non-rigid means of support (i.e. elastic bandages).▪ Use of non-prescription medication.▪ Removal of foreign bodies in the eye not embedded (i.e. by irrigation

or use of cotton swab).▪ Removal of foreign bodies in a wound by simple means (i.e. by use of

tweezers, cotton swab, irrigation).▪ Drilling of a nail to relieve pressure or draining fluid from a blister.▪ Cleaning, flushing or soaking wounds on the skin surface.▪ Superficial burns treatment – first degree burns.▪ Use of single dose prescription medication administered on the first

visit.▪ Oral antibiotics provided as a precautionary measure only (i.e. no

existing infection is to be considered first aid). For antibiotics (oral or intravenous) provided as treatment for an infection that is existing is to be considered Medical Treatment.

▪ Treatment includes RICE (i.e. Rest, Ice, Compression, Elevation).▪ Two (2) or less interventions by a licensed health care professional

(i.e. Physiotherapist, Chiropractor) upon referral of a medical practitioner.

▪ Superficial dental treatment such as smoothing chipped teeth or polishing.


Type Definition Inclusions / ExamplesMinor Injury – No Treatment

An injury caused by an actual specific incident for which no treatment is required.

▪ Visit to doctor or hospital for observation only or where negative diagnostic.

▪ Negative diagnostic procedures (i.e. x-ray, normal ECG).▪ Minor insect bite requiring no treatment.▪ Body part hit by moving object at low speed where no treatment is

required.▪ Body part hits an object at low speed in which no treatment is

required.

Near Miss An incident that has resulted in no personal contact, or damage to property assets or the environment but had the potential to do so.

▪ Examples include, an object falling from scaffold above narrowly missing a worker below.

Non-Work Related Any injury that occurs outside of work hours and has no known link to work activities. Any injury, illness or incident that results solely from normal body movements e.g. walking unencumbered, talking, sneezing, coughing, provided the action does not involve a job-related motion and the work environment does not contribute to the injury or illness.

▪ Sport activities.▪ Approved social activities.▪ Injuries resulting from travel to and from place of employment (work).▪ Injuries resulting from business appointed accommodation.▪ Incident occurs at home due to the home environment where

approved work is being carried out (i.e. tripping over dog).

Non-Work-Related incidents MUST also be documented to assist in mitigating any potential insurance or workers compensation liability claims and/or asset insurance. Costs associated with some non-work-related incidents that occur in Camp Accommodation may also be recoverable; therefore, full investigations may be required.

Procedural Breach Intentional, reckless or negligent deviation of a known procedure (including Safety Foundations) that is associated with an incident or incidents.

Examples include:▪ Working without correct permits (i.e. confined space entry, working

with heights, etc.).▪ Failure to wear PPE.▪ Failure to isolate, etc.


Type Definition Inclusions / ExamplesSecurity Event The violation of established physical and/or

informational barriers, designed to restrict the unauthorised use or access to people, company assets or sensitive information.

▪ Bomb threat.▪ Unauthorised access by third party.▪ Terrorist acts.▪ The unauthorised use, release, embezzlement, or obtainment of

intellectual or confidential property.▪ The unauthorised use of Company assets (such as vehicles).

Significant Environmental Incident

Contravention of a licence or permit condition requiring notification to the relevant authorities.

▪ Serious Pollution event, such as a Major Chemical Spill into a waterway.

▪ Damage or Destruction of protected flora or fauna and/or habitat.▪ Damage or Destruction to cultural heritage sites.

Environmental- Catastrophic

Widespread, irreparable environmental damage or harm is caused. This includes the loss of human life or long term human health effects.

▪ Catastrophic consequences may result in serious litigation or over $1 million to remediate or manage consequences.

Environmental – Major Widespread, medium to long term environmental impacts. This includes serious human health impacts, state-wide or national attention, a major breach of legal requirements that results in an offence being committed, major disruption to business operations and the business’s reputation or goodwill will be badly tarnished.

▪ Major consequences may result in serious litigation or between $100,000 to $1 million to remediate or manage consequences


Type Definition Inclusions / ExamplesEnvironmental –Moderate

Localised with medium to long term environmental impacts. Moderate consequences may result in a contribution to climate change, moderate human health impacts which may require medical treatment, local and regional media attention or a moderate breach of legal requirements with fines or infringements applying.

▪ A moderate consequence will cost between $10,000 to $100,000 to remediate and manage.

Environmental - Minor Localised short to medium term impacts including small contributions to climate change, minor and recoverable/treatable human health impacts.

▪ There may be some negative publicity from local media or minor breach of legal requirements resulting in infringements or warnings being issued by regulators and a cost of between $1,000 to $10,000 to manage or remediate consequences

Environmental - Insignificant

Limited impact to the business and local area with no long term environmental or health effects. Insignificant impacts may include concern or complaints from neighbours and are unlikely to result in an injury to people.

▪ This may include a minor technical or clients/contractor nonconformity but no legal nonconformity and would generally cost less than $1,000 cost to manage or resolve

Report Only Any incident that does not fall into any of the above classifications that Decmil record for reference purposes. A report only incident is for informational purposes only.

▪ The recurrence of a pre-existing injury.▪ Complaints of environmental emissions.▪ Significant mechanical faults identified in a pre-start inspection.▪ Where an incident was not caused by Decmil activities and details are

recorded for reference purposes only.


2. Responsibilities

2.1 Senior Management▪ Implement the requirements of this procedure as per assigned responsibilities.▪ Review major (both actual and potential) consequence and above incident classification reports.

2.2 Regional and Operations Managers▪ Implement the HSEMS within responsible operational areas of the business.▪ Ensure that the HSE, risk management and injury management policies are understood,

implemented and executed by Workplace Management and work towards “Zero Harm”.▪ Ensure that sufficient resources within their control are applied to fully implement all aspects of

this procedure.▪ Ensure notification and investigation requirements are carried out in accordance with this

procedure.▪ Support high and above, incident investigations.

2.3 Group HSEQ & Regional HSEQ▪ Provide advice and support in relation to this procedure where required.▪ Verify through audits and ongoing monitoring that Incident Management requirements are

implemented throughout the business.▪ Provide advice, training and support to all areas of the business in relation to this procedure and

participate in incident investigations for high (both actual and potential) consequence and above incidents as required by the Workplace Management Team.

▪ Review incident reports submitted.▪ Review, authorise and distribute HSE Alerts in response to high-potential and recordable

incidents.

2.4 Workplace Manager▪ Ensure that sufficient resources within their control are applied to fully implement all aspects of

this procedure.▪ Ensure that the correct personnel are trained to carry out investigations.▪ Ensure that client, external notification and incident investigation requirements are carried out in

accordance with contractual and statutory requirements.▪ Participate in incident investigations as required. ▪ Review and approve all incident reports and investigation findings ensuring adequacy and

implementation of all corrective actions.▪ Ensure an appropriate number of qualified first aiders are appointed. ▪ Notify relevant personnel as per the escalation Matrix in Section 3.4 Actual / Potential Incident

Classification and Escalation.▪ Maintain and manage the privacy and confidentially of personal and health information pertaining

to an injured worker or person in accordance with the requirements of the privacy legislation.


2.5 Workplace HSE Personnel or Delegate (i.e. Supervisor / Engineer)▪ Ensure that this procedure is understood and implemented.▪ Contain the area and carry out initial investigation at the scene of an incident.▪ Ensure investigation recommendations and actions are closed off.▪ Ensure notification and investigation requirements are carried out in accordance with this

procedure.▪ Review and investigate all incidents including non-work related incidents.▪ Liaise with the Client / other parties in relation to incident investigations.▪ Support the responsible Supervisor and workforce in the identification, reporting, and investigation

of incidents.▪ Provide advice on how to implement this procedure.▪ Support the Workplace Management Team with their responsibilities as documented in this

procedure.▪ Assist with recording and facilitating higher level investigations.▪ Forward incident reports to the Workplace Manager for review and approval.▪ Ensure notification to statutory authorities in accordance with legislative requirements.▪ Maintain contact with the injured worker or person. (Refer to HSE-SWP-090-01 Workers

Compensation and Injury Management Procedure).

2.6 Employees and Subcontractors▪ Notify the responsible supervisor of all incidents immediately.▪ Participate in incident investigations as required.

2.7 Health and Safety Representatives▪ Participate in incident investigations as required.▪ Review incidents at the monthly HSE Committee Meeting (where applicable).


3. ProcedureCMO Compliance is used to record all incidents and actions. It is an online system which allows real time capture of information and automatic notification of incidents and actions to relevant stakeholder/s.

Depending on the workplace; Client incident reporting and action management systems may be required in addition to CMO Compliance.

3.1 Reporting of IncidentsAll personnel are responsible for reporting incidents and hazards to the responsible Supervisor or Manager as soon as possible after becoming aware of the hazard or incident.

Raising the alarm and contacting the Emergency Response Team (ERT) must take precedence.

The responsible Supervisor or Manager (known as the Reporter in CMO) is to input and submit for review the initial report details within CMO and shall endeavour to do this within the same shift in which the incident or hazard is reported to them.

3.2 Immediate Action Post IncidentThe scene of an incident must be secured and not disturbed unless actions are required to save a life or prevent further loss.

The responsible Supervisor or Manager shall:

▪ Initiate the Emergency Response Management Plan.▪ Activate the crisis management process if the incident requires a crisis management response.

(Refer to EM-PR-040 Crisis, Emergency Management and Business Continuity Management System).

▪ Inspect the scene to gather evidence prior to any further disturbances.▪ Identify and implement immediate corrective action necessary to prevent escalation of the incident

or further incidents from occurring.▪ Preserve the incident scene in a manner consistent with their responsibility to retain valuable

information for the investigation.▪ Carry out a preliminary assessment of the incident.▪ Determine the necessary level of investigation.▪ Test for substance abuse.▪ Photograph / video / sketch the scene before changes are made.▪ Ensure perishable evidence is preserved and photographed in-situ.▪ Identify all witnesses / participants who may have information about the incident and plan to

conduct all interviews.▪ Escalate the initial notification depending on the consequence or potential consequence level.If it is a significant incident, work must immediately cease, and must not resume until preventive actions have been taken and the resumption of work has been authorised by the Workplace Manager.

3.3 Classification of IncidentsThere can only be one classification applied to an incident, although there maybe multiple classifications associated with a single incident. The hierarchy of classifications is to be applied in the following order – People, Environment, Property, Procedural Breach and then Near Miss.


3.4 Actual / Potential Incident Classifications and EscalationThe table below outlines who is to be notified when an incident occurs depending on its classification.Table 2

Consequence Level People Environment Responsible Person to Escalate Escalation Level

Catastrophic Fatality (Death) / Multiple permanent disability injuries

Widespread, irreparable environmental damage or harm

Workplace Manager

▪ Board

▪ Managing Director

▪ EGM - Region

▪ EGM - Commercial & Risk

▪ Regional Manager

▪ Operations Manager

▪ Workplace Manager

▪ Group & Regional HSEQ

Immediate verbal communication followed by written notification within shift

Major Permanent disability injury or illness

Widespread, medium to long term environmental impact

Workplace Manager

▪ Managing Director

▪ EGM - Region

▪ EGM - Commercial & Risk






Moderate Recordable injury/s

Localised with medium to long term environmental impact

Workplace Manager

▪ EGM – Region

▪ EGM – Commercial & Risk






Minor First aid injury/s

Localised short term environmental impact

HSE Advisor / Supervisor





Written notification within shift


Consequence Level People Environment Responsible Person to Escalate Escalation Level

Insignificant Injury/s but no treatment required

Minor environmental impact

HSE Advisor / Supervisor



Written notification within shift

Non-Work Related HSE Advisor / Supervisor



Notification of incident and level of details required shall be based upon potential or actual severity

Property Damage HSE Advisor / Supervisor



Written notification within shiftProcedural Breach

Security EventCommunity ComplaintNear Miss

Report Only

Notification of high potential incidents shall adhere to the requirements of the above table in relation to their potential to have resulted in an injury or environmental damage of a minor to catastrophic level, regardless of whether the event is a Procedural / Security Breach, Near Miss or Community Complaint.

Additionally, incidents that relate to the HSE-GL-010-002 Safety Foundations must be reported to the Executive General Manager – Region, Executive General Manager - Commercial & Risk, Regional Manager, Operations Manager, Workplace Manager and Group & Regional HSE as a minimum.

3.5 Reviewing Initial Incident ReportsA workplace HSE Advisor or delegate shall complete a review of initial incident reports submitted via the CMO system. This review requires that:

▪ The content of the incident report be reviewed, amended or endorsed;▪ A risk rating be applied to the event;▪ Determination of notification requirements to relevant statutory or other third parties is determined

and recorded;▪ Safety Foundation contraventions are identified;▪ HR involvement needs determined and assigned; and▪ The incident submitted for investigation.


3.6 Investigating an Incident▪ Care for the injured first, i.e. first aid, medical attention, etc.▪ Prevent secondary incidents where this is likely.▪ Use HSE-TP-080-02-002 Incident Investigation Checklist to provide guidance on steps to take to

investigate the incident.▪ Collect information under five main headings:

▪ People.▪ Environment.▪ Equipment.▪ Procedures and documents.▪ Organisation.

▪ Photograph the scene and ensure the date and time stamp is on all photographs taken.▪ Determine eye witnesses, and anyone with relevant information.▪ The investigation team shall identify all actions or deficiencies that may have been contributing

factors to the incident by asking the following questions - Who, What, When, Where, Why and How. For most of these questions, an important follow up question is, “if not, why not”?

▪ Examine the area / equipment / materials involved.▪ Preserve the evidence, i.e. samples / photographs / sketches / maps.▪ Notify Workplace Management.▪ Interview witnesses.▪ Review supporting procedures and documents, i.e. SWMS or JHA.▪ Establish the facts.▪ Decide on and implement immediate corrective action.▪ Select the correct report forms.Taproot techniques shall be applied when investigating incidents reported.

Refer to Appendix A for a list of questions that may assist investigators to establish the facts.

All evidence gathered by the lead investigator is to be loaded up to the CMO system against the relevant incident event, unless the incident is subject to legal privilege.

3.6.1 Investigation Teams

▪ Decmil supervision shall utilise the services of their Leading Hands and employee elected Health and Safety Representatives when conducting incident investigations. These personnel shall form the investigation team in the event of a reported incident, under the direction of the Responsible Decmil Supervisor.

▪ The Workplace Manager with the assistance of HSE personnel shall be responsible for leading investigation teams in the event of an incident that has been classified as having an actual and/or potential consequence rating of moderate and above.

▪ In certain investigations input of a specialist nature may be required e.g. plant failure may require the assessment of trained workshop and plant personnel, input from subcontractors, advice from manufacturers, independent specialist consultant and/or expert opinion.

▪ Taproot techniques shall be applied to compile all incident investigation information gathered for causal analysis purposes.

▪ Regional and Operations Management and Regional HSEQ shall participate if requested in taproot investigations and review all taproot investigation reports for approval. The review is to ensure suitable corrective actions are implemented against the root causes identified and agreed.


▪ If the Client has a different classification schedule and requests a different investigation model to be used (i.e. ICAM, etc.) it shall be implemented and documented in the relevant Workplace HSE management plans.

NOTE: Fatalities or Permanent Disability Injuries shall be investigated by independent external industry specialists, i.e. Legal Counsel, OHS Consultant, etc.

3.6.2 Interviewing a Witness

▪ Obtain a witness statement first using HSE-TP-080-02-001 HSE Witness Statement. This statement shall be used to develop questions for interview and/or to determine whether an interview is necessary given the witness’s account of the incident.

▪ Take time to gather all background information prior to the interview to ensure a successful interview.

▪ Prioritise witness interviews according to availability or relationship to occurrence.▪ Find a suitable private location, either at the scene or in an office.▪ Conduct the interview as soon as possible after the incident.▪ Record witness interviews separately and with another member of the Workplace Management

Team present. Joint outside discussions will influence the witness’s account of events resulting in an inaccurate statement.

▪ Put interviewee at ease and be attentive, i.e. avoid boss / subordinate syndrome.▪ Start with easy answers, i.e. answers which are known.▪ Get the witnesses own version. Do not interrupt.▪ Use everyday language.▪ Take detailed notes during the interview by using HSE-TP-080-02-003 Incident Interview Record.▪ Make no judgements / opinions. Simply get the facts.▪ Give feedback. Summarise to ensure understanding.▪ If possible, use visual aids / actual items.▪ Thank the interviewee. Ask them to come back to you if anything further is remembered.▪ Ensure the witness reads, signs and dates both the witness statement and interview record so

correct interpretation and accuracy is achieved.▪ End the interview on a positive note.▪ Follow up with witnesses, as additional details relating to the incident may be recalled within a few

days.


4. HSE Incident Report

4.1.1 Determine the Sequence of Events

The incident investigation team shall identify a sequence of events as soon as possible after the incident, based on information known at the time. Further data shall then be gathered to complete this sequence and identify associated conditions or facts.

Data collected during an investigation shall be organised and entered into CMO. The sequence of events depicted shall start at a point where the operation was normal and end where normal operation resumes. This may mean going back or forward a number of days or weeks.

All known facts shall be included in the sequence (timeline) to show:

▪ Events leading up to the incident;▪ The incident itself; and▪ Events post incident.Use HSE-TP-080-02-005 Taproot Snap Chart Template to develop the sequence (timeline).

4.1.2 Determine Causal Factors

Causal factors are conditions or events that if corrected, could have prevented the incident from occurring or would have significantly reduced its consequence. Causal factors can include:

▪ Characteristics of the activity / task being performed.▪ Work situation.▪ Physical and social environment.▪ Physical and emotional state of person(s) involved.Use the timeline when identifying causal factors.

4.1.3 Identify Root Causes

Root causes shall be identified using root cause analysis techniques with all incident investigations.

4.1.4 Develop Corrective Actions

Each root cause shall have an action identified. Corrective actions shall be developed with consideration of the hierarchy of controls. The ‘SMARTER’ approach detailed below shall be used to assist with developing actions. The investigation team shall determine who has the authority and responsibility to implement identified corrective actions. The investigation team leader shall discuss actions with responsible persons to ensure they are within their capability and to obtain agreement on the scope of work and timeframes for completion.

SMARTERS Specific Who will do what and when?M Measurable Can it be measured to see when it is done and to determine whether it

works?A Accountable Is a responsible person clearly identified to implement the action?R Reasonable Is the action practical? Is there a simpler or less expensive way to do the

same thing? Has the action been discussed with those responsible for implementation?

T Timely Is the due date soon enough, given the potential for incident recurrence?E Effective Will the action prevent or significantly reduce the chance of the incident

recurring?R Reviewed Will the action introduce any other hazards? Has someone external to the

investigation team reviewed the action?


Where corrective actions are subject to budget expenditure or extended close outs, immediate or short-term corrective actions shall be implemented as an interim measure to prevent recurrence. Once actions have been identified they will be entered into CMO. Once actions are agreed it shall trigger a review of the workplace risk assessment. The Workplace Manager shall review the status of corrective actions at team meetings. Overdue corrective actions automatically escalate within CMO to management levels above for follow up and performance management if timeframes are not met.

4.1.5 Incident Investigation Report Review and Approval

It is a requirement for incident investigation reports to be reviewed and approved by workplace management to acknowledge the identified causal factors, root cause/s and endorse the recommended corrective actions.

By endorsing the recommended actions, the reviewer / approver is acknowledging the investigation report as sufficient, complete and the reviewer is satisfied that the investigation into the incident can be approved and closed out. Preparation of the final incident investigation report may be required using HSE-TP-080-02-004 Taproot Investigation Report Template.

4.1.6 Issue Resolution

If an issue arises after an incident has occurred and parties are unable to come to a common understanding regarding findings from the investigation into the event, then the Company issue resolution process shall be followed to resolve the matter. Refer to the HSE-PR-070 HSE Consultation and Communication Procedure.


5. CALCULATION OF HPIFR, TRIFR AND AIFR

5.1 To calculate HPIFR, use the following formula: (Number of high-potential incidents reported in accounting period)

---------------------------------------------------------------- × 1 000 000

(Total hours worked in accounting period)

5.2 To calculate TRIFR, use the following formula: (Number of total recordable injuries in accounting period)

---------------------------------------------------------------- × 1 000 000


5.3 To calculate AIFR, use the following formula:(Number of all injuries in accounting period)

------------------------------------------------ × 1 000 000


6. Workers Compensation and Injury ManagementRefer to HSE-SWP-090-01 Workers Compensation and Injury Management Safe Work Procedure.

7. Legal Professional PrivilegeIn consultation with the Group HSEQ National Manager, Decmil’s Legal Counsel shall be contacted in regard to the protection of incident investigation documentation from disclosure where required. This shall typically be in response to a potential breach of statutory legislation and/or significant insurance matter. Refer to HSE-PR-030 HSE Legal Obligations and Other Requirements Procedure.


Fatality

Lost Time Injury

Restricted Work Injury

Medical Treatment Injury

First Aid Injury

All Injury injuries / illnessesTotal Recordable Injuries / Illnesses

8. CommunicationWhen an incident has occurred, the responsible Workplace Manager shall communicate the details of the incident at their next pre-start and toolbox meeting to detail the immediate facts of the case that are available within the first 24 hours. High potential and recordable incidents shall require an immediate ‘Stop Work’ briefing with the entire workforce. This is essential to assist in preventing similar occurrences.

The responsible Workplace Manager where a high potential or recordable incident has been reported shall ensure a HSE-TP-070-005 HSE Alert is developed with support from HSE Personnel. This must be submitted to the Group & Regional HSEQ Department within 24 hours of completion and approval of the investigation report. This Alert shall be posted on DECNET and e-mailed to all HSE Personnel, Workplace Managers, Regional Managers, Operations Managers, the Executive General Manager, Managing Director and Board. These alerts shall be communicated to all personnel via the pre-start or toolbox meeting process.

8.1 Incident DebriefThe Workplace Manager with assistance from HSE personnel shall conduct an ‘Incident Debrief’ for incidents classified as having an actual and/or potential consequence rating of moderate and above with the persons involved in the incident after the investigation process to explain: ▪ The outcome of the incident; ▪ The outcome of the investigation; and ▪ Any corrective / preventive measures that have been or will be taken.

9. Statutory and/or Third-Party Reporting RequirementsAll relevant incidents shall be reported to the responsible statutory body or relevant third party in accordance with legislative or other requirements. This shall be the responsibility of Workplace HSE Personnel or the Group & Regional HSEQ Department. The authorities shall be notified by telephone initially to receive a Reference Number and the report shall follow within the timeframe assigned.

Notifiable incidents to the responsible statutory body or other third party, i.e. WorkSafe, OFSC, Comcare, etc. are detailed on the relevant statutory body’s website.

▪ Refer to http://www.safeworkaustralia.gov.au/sites/swa/whs-information/workplace-incidents-reporting/pages/workplace-incidents-reporting for incident reporting to the applicable jurisdiction and associated report forms.

▪ Notifiable incidents to WorkSafe can be found here - https://www.safeworkaustralia.gov.au/system/files/documents/1702/incident-notification-fact-sheet-2015.pdf.

▪ OFSC Notifiable incidents and the notification template are located here - http://www.fsc.gov.au/sites/FSC/Resources/AZ/Documents/OFSCIncidentReport.pdf

▪ Comcare notification form can be located here -https://www.comcare.gov.au/Forms_and_Publications/forms2/safety_and_prevention_forms/safety_and_prevention/notification_of_incidents_occurring_on_or_after_1_january_2012

▪ Certain electrical incidents are also reportable to the relevant statutory body. For example, in WA this is Energy Safety https://www.commerce.wa.gov.au/energysafety/report-accident, in QLD the Electrical Safety Office https://www.worksafe.qld.gov.au/laws-and-compliance/incidents-and-notifications and in VIC this is Energy Safe Victoria http://www.esv.vic.gov.au/Legislation-Regulations/Legislation-and-guidelines-by-topic/Incident-reporting.

▪ New Zealand notification of incidents; https://worksafe.govt.nz/notify-worksafe


▪ For environmental incidents notification shall be made to the relevant statutory body.

Western Australia http://www.der.wa.gov.au/your-environment/reporting-pollution/report-pollution-form

Queensland https://www.qld.gov.au/environment/pollution/reporting/

Victoria http://www.epa.vic.gov.au/get-involved/report-pollution

South Australia http://www.epa.sa.gov.au/our_work/incident_reporting

New Zealand http://www.mfe.govt.nz/more/environmental-reporting

Northern Territory https://ntepa.nt.gov.au/waste-pollution/hotline/pollution-report-form

New South Wales http://www.epa.nsw.gov.au/pollution/index.htm

New Zealand Contact Local Council

Statutory reporting information shall be recorded and uploaded to CMO for the incident.

Clients are to be notified in accordance with contractual requirements as specified within Workplace HSE Management Plans.

10. TrainingDecmil Supervisors and Workplace Managers shall complete internal training in investigation techniques, especially the skills required to effectively interview witnesses. This training shall be provided through the relevant Career Pathway programs and aligned with the nationally recognised unit of competence RIIWHS301D Investigate Health and Safety Incident.

HSE personnel shall have completed basic Taproot Incident Investigation and Root Cause Analysis training.

Workplace Managers, Regional Managers and Operation Managers, and should complete basic Taproot Incident Investigation and Root Cause Analysis training.

CMO system training shall be provided to all Decmil staff responsible and/or involved in incident reporting, review, investigation and approval processes, including training in this procedure.


Appendix A - Establishing the Facts – Questions to Ask

WHO

▪ Was injured?▪ Saw the incident?▪ Was working with the injured person/s?▪ Had instructed and/or assigned the job?▪ Else was involved?▪ Has information on circumstances / events prior to the incident?▪ Administered first aid?

WHAT

▪ Is the injury?▪ Is the damage or loss?▪ Was the injured person/s doing?▪ Is the work process?▪ Had the injured person/s been instructed to do?▪ Tools were being used?▪ Machinery / plant / equipment was in use?▪ PPE was being worn?▪ Previous similar incidents have occurred?▪ Action had been taken to prevent recurrence?▪ Did the injured person/s and any witnesses see?▪ Safety rules were violated?▪ Safe systems of work, permits to work, isolation procedures were in

place?▪ Training had been given?▪ Were the contributing causes of the incident?▪ Communication system was in use?▪ Were the weather conditions?

WHY

▪ Did the injury occur?▪ Did communication fail?▪ Was training not given?▪ Were there unsafe conditions?▪ Was the hazard not evaluated?▪ Was the system of work inadequate or inappropriate?▪ Was personal protective equipment not provided?▪ Was protective equipment not used?▪ Was there no safe system of work, permit to work or isolation procedure

operating?▪ Were specific safety instructions not given?▪ Was the supervisor not consulted when things started to go wrong?▪ Was the supervisor not there at the time?

WHERE▪ Did the incident occur?▪ Did the damage occur?▪ Was the supervisor at the time?▪ Were the witnesses at the time?

WHEN

▪ Did the incident occur?▪ Did the damage become evident?▪ Did the injured person/s start the job?▪ Was an explanation of the hazards given?▪ Did the supervisor last see the injured person/s?▪ Was something seen to be wrong?

HOW▪ Did the injury occur?▪ Could the incident have been avoided?▪ Could the injury have been avoided?▪ Could the supervisor have prevented the incident?▪ Could better design of plant or systems of work helped?
