Catholic Safety, Health & Welfare South Australia

PARISH SECTOR
ACCIDENT/INCIDENT/NEAR MISS REPORTING
Sector Approved: 11 October 2010

Policy Reference

No. 2

Version No. 3
Page 1 of 12

Review Date: October 2013

PURPOSE: A formal process to report and investigate all workplace accidents, incidents and near
miss occurrences. This process includes identifying contributing factors of the accident, incident, near miss or hazardous situation and making the necessary recommendations to prevent a recurrence.

RESPONSIBILITIES: MANAGERS:
Managers are responsible for but not limited to: To ensure all accidents, incidents and near miss incidents are reported and investigation commenced within 24 hours. Ensuring workers are provided with training to understand their responsibilities and carry out their role in incident reporting, the investigation process and associated documentation. Effective consultation occurs following an accident, incident or near miss. Where controls are implemented effective monitoring and review occurs. Information/feedback is provided e.g. meetings, persons involved in incident.

P R O C E D U R E

EMPLOYEES/VOLUNTEERS:
Employees/Volunteers are responsible for: Reporting accidents, incidents, near misses. Following all reasonable instruction and training provided in relation to their health & safety at work. Taking reasonable care to avoid adversely affecting the health & safety of themselves or others through an act or omission at work.

Employees/Volunteers are actively encouraged to assist with the investigation process and implementation of control measures.

ACTIONS: What:
Minor Injuries Apply appropriate first aid treatment and record on First Aid Register (Form 2c) Review First Aid Register Ensure incidents where appropriate are investigated

CHECK IF THIS IS A NOTIFIABLE INCIDENT REFER APPENDIX 2 IF UNSURE CONTACT YOUR CSH&WSA CONSULTANT Accidents/Incidents/Near Miss Reporting (Injury without Workers Compensation Claim) Report the injury or incident to Manager Complete Accident/Incident/Near Miss Report Form (Form 2a) Conduct investigation of incident (commence within 24 hours) All contributing factors identified and recommendations made Implement controls Review controls Information/feedback to meetings, employee involved in

Catholic Safety, Health & Welfare South Australia

ACCIDENT/INCIDENT/NEAR MISS REPORTING No.2 Version No. 3 Page 2 of 12

incident Reporting an Injury with a Workers Compensation Claim (Procedure 23) Any identified hazards are entered onto the Hazard Register (Form 14d) MUST be entered on the online Incident Database (CSH&WSA) Complete Workers Compensation Form as soon as possible and forward to Catholic Church Insurances within three (3) working days Attach to the Workers Compensation Form: Investigation Process for all of the above (Document 2b) Medical Certificate Copy of completed Incident Report Form (Form 2b) Employee Report Form

As above

P R O C E D U R E

Contact your sites Rehabilitation and Return to Work Coordinator Date & time Exact Location Activity/task being undertaken What happened Contributing Factors people, environment, plant, equipment, materials, lighting, guarding, substances, weather, noise, housekeeping Actions implemented to prevent reoccurrence using Hierarchy of Controls Hazard Register (Form 14d) updated Do not alter the scene Notify CSH&WSA Consultant for assistance in: Notifying SafeWork SA

Report to cover the following:

Notification of Certain Work Related Injuries and Dangerous Occurrences APPENDIX 2

Notifying OTR for electrical/gas incidents Information required: Name and address of the person giving notice Date and time of the event The place where the dangerous occurrence happened The apparent cause The nature and the extent of the damage The work that was being carried out

Debriefing for serious accident/incident/near miss which has had an impact on other Employees/Volunteers Notifiable Communicable Diseases Documentation Control

Support, debriefing and access to counseling e.g. Access OCAR

Report any incidents of notifiable communicable disease if unsure contact CSH&W SA Accident/ Incident/Near Miss forms kept for a 5 year period First Aid Register kept for a 5 year period

Catholic Safety, Health & Welfare South Australia

ACCIDENT/INCIDENT/NEAR MISS REPORTING No.2 Version No. 3 Page 3 of 12

TRAINING:
All Employees/Volunteers will be informed in the requirements during induction. Those responsible for investigating any accident/incident/near miss as part of their role will be trained in the requirements in line with this procedure. Instruction and information will be provided to all Employees/Volunteers if procedure is amended.

P R O C E D U R E

MONITOR & REVIEW:

This procedure will be monitored for compliance and effectiveness in accordance with Audit Procedure Document No 7, or at any time pursuant to either legislative or CCES policy change. Review will be in consultation with Sector Forums at least 3 yearly.

RELATED DOCUMENTS
EXTERNAL DOCUMENTS: OHS&W Act 1986, Section 19 Duty of Care OHS&W Regulations 2010 Workers Rehabilitation and Compensation Act 1986 Australian Standard 1885.1 1990 Workplace Injury and Disease Recording Standard Schedule 1 Public and Environmental Health Act 1987 INTERNAL DOCUMENTS Catholic Church Safety Manual CCSM Procedure 14 Hazard Management CCSM Procedure 11 First Aid CCSM Procedure 23 Workers Compensation and Rehabilitation APPENDICES: Appendix 1 - Definitions Appendix 2 Division 6.6 Occupational Health & Safety Regulations 2010 Notification of Certain Occurrences Appendix 3 Contact Details Telephone Numbers FORMS Form 2a Accident/Incident/Near Miss Form Form 2b First Aid Register

Catholic Safety, Health & Welfare South Australia

PARISH SECTOR
ACCIDENT/INCIDENT/NEAR MISS REPORTING
Sector Approved: 11 October 2010

Policy Reference

No. 2

Version No. 3
Page 4 of 12

Review Date: October 2013

APPENDIX No: 1
DEFINITIONS:
Accident Corrective Action An unforeseen event that causes injury or death Is an action taken after an incident to correct the problem and to reduce the risk of a similar incident occurring An injury that results in loss of life A situation that has the potential to harm a person, environment or damage to property. Nominated person to assist Employees/Volunteers to have health & safety issues raised. HSR have legal rights and functions to assist them to carry out their role effectively. An occurrence or event that caused or could cause harm (injury, illness or damage) A systematic examination of an event and its cause/contributing factors to persons, plant, material or the environment. Those occurrences that resulted in a fatality, permanent disability or time lost from work of one day/shift or more. A person appointed to manage the activities of day to day running of a worksite e.g. Parish Priest, Pastoral Director, Pastoral Associate An injury that requires no medical attention Any unplanned incident that occurred at the workplace which, although not resulting in any injury or disease, had the potential to do so. (a) a communicable disease included in Schedule 1 (Public and Environmental Health Act 1987); or (b) a communicable disease prescribed by regulation to be a notifiable disease; Appendix 2 Electrical & Gas authorities for South Australia Harm caused to something owned

Fatality Hazard Health & Safety Representative (HSR) (where applicable)

Incident Investigation

Lost Time Injuries/Diseases

Manager

Minor Injury Near Miss

Notifiable Communicable Diseases

Notifiable Incident Office of the Technical Regulator (OTR) Property damage

Catholic Safety, Health & Welfare South Australia

PARISH SECTOR
ACCIDENT/INCIDENT/NEAR MISS REPORTING
Sector Approved: 11 October 2010

Policy Reference

No. 2

Version No. 3
Page 5 of 12

Review Date: October 2013

APPENDIX No: 2

NOTIFY CSH&WSA OHS CONSULTANT OR THE OHS MANAGER 0438 396 062 OR DURING OFFICE HOURS 8210 9342
PART 7, DIVISION 6 OHS&W REGULATIONS REGULATION 417 - NOTIFICATION OF CERTAIN OCCURENCES Preliminary (1) For the purpose of this Division the following are immediately notifiable work related injuries: (a) a work related injury that causes death; (b) a work related injury that has acute systems associated with exposure to a substance at work; (c) a work related injury that requires treatment as an in patient in a hospital immediately after the injury (disregarding any time taken for an emergency treatment or to get the person to hospital) (2) For the purpose of this Division, a notifiable dangerous occurrence means an incident or event (a) Where there is an immediate and significant risk to any person in, on or near the relevant place, or who could have been in, on or near the relevant place (whether or not a work related injury occurs); and (b) that is attributable to any of the following: (i) the collapse, overturning or failure of the load bearing part of a scaffolding, lift, crane, hoist or mine-winding equipment (ii) damage to, or malfunction of, other major plant; (iii) the unintended collapse or failure of an excavation that is more than 1.5m deep, or of any shoring; (iv) the unintended collapse or partial collapse (A) of a building or structure under construction, reconstruction, alteration, repair or demolition; or (B) the floor, wall or ceiling of a building being used as a workplace; (v) an uncontrolled explosion, fire or escape of any gas, hazardous substance or steam; (vi) the unintended ignition or explosion of an explosive; (vii) an electrical short circuit, malfunction or explosion; (viii) an unintended event involving a flood of water, rock burst, rock fall, or any collapse of ground; (ix) an incident where breathing apparatus intended to permit the user to breathe independently of the surrounding atmosphere malfunctions in such a way that the wearer is deprived of breathing air or exposed to an atmospheric contaminant to an extent that may endanger health; (x) any other unintended or uncontrolled incident or event arising from operations carried on at a workplace. (3) In this DivisionDepartment means the Department of the Minister to whom the administration of the Act is committed.

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ACCIDENT/INCIDENT/NEAR MISS REPORTING No. 2 Appendix 3 Page 6of 12

418 NOTIFICATION OF WORK RELATED INJURIES (1) Subject to these regulations, if an employee suffers an immediately notifiable work related injury the employer must notify the Department of the injury by telephone or facsimile as soon as practicable after the occurrence of the injury. (3) Subject to these regulations (4) if an employee suffers an immediately notifiable work related injury, the employer must not, without the permission of an inspector(a) Alter the site where the injury occurred; or (b) Reuse, repair or remove any plant, or reuse or remove any substance that caused, or was connected with the occurrence of, the death or injury. (4) An employer must, pending the granting of permission by an inspector under subregulation (3) take such steps as are necessary(a) To rescue an injured person; or (b) To retrieve a dead body; or (c) To protect the health or safety of any person who may be in the vicinity of the site, and may prevent undue damage to property. 419 NOTIFICATION OF DANGEROUS OCCURENCES (1) Subject to these regulations, if a notifiable dangerous occurrence occurs at a workplace, the person in charge of the workplace must give notice of the occurrence as follows: (a) the person must give preliminary notice of the occurrence by contacting the Department by telephone of facsimile as soon as practicable after it occurs; and (b) the person must give written notice of the occurrence by sending to the office of the Department a notice in a form determined by the Director containing the information required under sub regulation (2) within 24 hours after it occurs. (2) A written notice under sub-regulation (1) (b) must include the following information: (a) (b) (c) (d) (e) (f) the name and business address of the person giving notice; the date and time of the dangerous occurrence; the place of the dangerous occurrence the apparent cause of the dangerous occurrence the nature and extent of any damaged caused; the work (if any) that was being carried out at the time of the dangerous occurrence.

Catholic Safety, Health & Welfare South Australia

PARISH SECTOR
INCIDENT/ACCIDENT/NEAR MISS REPORTING
Sector Approved: 10 October 2010

Policy Reference

No. 2

Version: 3
Page 7of 12

Review Date: October 2013

APPENDIX 3

CONTACTS Police/Fire/Ambulance Catholic Safety, Health & Welfare SA

TELEPHONE NUMBERS 000 General office hours: (08) 82109342 24 hours/7 days 0438 396 062 1300 667 700
Email address: www.accesspl.com.au

Access OCAR Employee Assistance Program Catholic Church Insurances Communicable Disease Control Branch (CDCB) Environment Protection Authority (Pollution Hotline) Office of the Technical Regulator SafeWork SA

(08) 8236 5400 (08) 8226 7177 or Facsimile (08) 8226 7187 1800 623 445 or (08) 8204 2004 For all electrical and gas incidents 1800 558 811 Telephone 1800 777 209 (24 hours) Facsimile: (08) 8204 9200

Catholic Safety, Health & Welfare South Australia

PARISH SECTOR
INCIDENT/ACCIDENT/NEAR MISS REPORTING
Sector Approved: 11 October 2010

Policy Reference:

No. 2

Form No: 2a (Version 3)

Page 1 of 4

Review Date: October 2013

INSTRUCTIONS
This form is to be used to report all incidents and accidents including near misses. All occurrences must be reported to your immediate supervisor/manager as soon as practicable and within 24hrs. Part A Part B To be completed by the injured person or another person on behalf of the injured person. To be completed by the Manager/Supervisor in consultation with ALL affected parties, Health & Safety Representative to be informed. Completed in the case of a sustained injury by either the person involved and/or the person conducting the investigation.

NOTIFICATION OF CERTAIN WORK RELATED INJURIES AND DANGEROUS OCCURRENCES OHS&W Regulations 2010 Part 7 Div. 6 Notification of Certain Occurrences Any injury resulting in death or requiring treatment as an in-patient in a hospital, acute symptoms associated with exposure to a substance. Dangerous occurrences Electrical short circuit, malfunction or explosion, uncontrolled explosion, fire or escape of gas, hazardous substance or steam. Reason for notification: ....................................................................................... ............................................................................................................................. Have you contacted your OHS Consultant? Yes No NOTE: CSH&W after hours ph 0438396062 Has SafeWork SA been notified within 24 hrs? SafeWork SA contact No: 1800 777 209 Yes No

Part C

If a claim is to be lodged please forward a copy of the full report to CCI within 3 working days from the date of the injury.

WORKSITE: _____________________________________________________________________________________________

ACCIDENT / INCIDENT / NEAR MISS REPORT FORM

Incident resulted in: No Injury Damage to property Injury (No lost time) Date of Incident Date Reported Reported to Injury (lost time) Exacerbation of previous Injury Near Miss Position of person involved/injured: Employee Visitor Volunteer Time of Incident Time Reported Self-employed Contractor Other _____________________________ AM/PM AM/PM

PART A
NAME OF PERSON INJURED/INVOLVED:
Surname:_______________________________________________Given Name/s______________________________ Date of Birth

............ / ............ / ............

Gender (M / F)

Occupation/Job Title_____________________________________________ Contact Phone No. (Wk)_________________ (Hm) _______________________ (Mob) _________________________ Home Address ________________________________________________________________________________________________

NAME OF PERSON SUBMITTING DETAILS: (if different from above)

Surname____________________________--- Given Name/s______________________________________________ Contact Phone No.(Wk) _________________ (Hm) _______________ (Mob) ________________

NAME OF PERSON/s WHO WITNESSED INCIDENT OR FIRST CAME TO SCENE:

_____________________________________________________________________________________________________________ Surname Given Name/s Contact Phone No. (Wk)_________________ (Hm) _______________ (Mob)________________
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Catholic Safety, Health & Welfare South Australia

ACCIDENT/INCIDENT/NEAR MISS REPORTING No. 2 (Where there is more than one witness attach extra sheet with details) Form 2b Version No. 3 Page 2 of 4

LOCATION: (Physical Location)

_____________________________________________________________________________________________________________

SPECIFIC AREA: (eg Particular building/room, while in transit (vehicle etc)

_____________________________________________________________________________________________________________

DESCRIBE ACTIVITY BEING UNDERTAKEN: Identify any plant/substance/equipment involved (Attach pages if
required) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

PART B Details of incident/investigation

DATE OF INVESTIGATION../../ WHAT HAPPENED? Please include a description of events:
_____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________

WHAT FACTORS CONTRIBUTED TO THE ACCIDENT/INCIDENT/NEAR MISS?

People: (eg culture, language, fatigue?) _____________________________________________________________________________ _____________________________________________________________________________________________________________ Total hours worked when incident occurred ____________hrs Environment: (eg lighting, temperature, wind?) _______________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Plant/Equipment: (eg guarding, maintenance, type of plant/equipment?) ___________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Materials: (eg suitable for task, clothing, footwear, personal protective equipment, materials used?)______________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Procedure/Job/Task: (eg appropriate procedure, task organisation, training, SOPs, supervision?) ______________________________ _____________________________________________________________________________________________________________

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Catholic Safety, Health & Welfare South Australia

ACCIDENT/INCIDENT/NEAR MISS REPORTING No. 2 Form 2b Version 3 Page 3 of 4

LIST ACTIONS TO PREVENT REOCCURRENCE Manager/Supervisor should complete in consultation

with the OHS Committee and Health & Safety Representative where applicable. Immediate Action Taken _______________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Interim Controls: (Short Term) _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Proposed Permanent Controls _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ _____________________________________________________________________________________________________________ Hazard Register updated Yes No Ref No_______________

Risk Assessment Ref No______________

Incident Database ID: _______________________

USE HIERARCHY OF CONTROLS in descending order: 1 2 3 4 5 ELIMINATION SUBSTITUTION ENGINEERING ADMINISTRATION PERSONAL PROTECTIVE EQUIPMENT Can you eliminate the hazard altogether Can you substitute less hazardous equipment, substances or agents Would the hazard be reduced by ventilation, barriers or isolation Is training, policy or safe working procedures required What personal protective equipment (PPE) would be appropriate

Has feedback been provided to person/s involved in the incident:

Yes No

Date../../..

SIGN OFF
Person Involved: Signature: __________________________________ Date: / /

Person Reporting (if different from above): Signature: __________________________________ Date: / /

Name of person Investigating incident: ______________________________________ (print name) Signature: __________________________ Date: / /

Name of OHS Co-ordinator/Health and Safety Representative: _______________________________________ (print name) Signature: __________________________________ Date: / /

MANAGER/SUPERVISOR I confirm the details of the incident reported and agree with the recommendations made. Name: _________________________________________ Date: / / Ph: _____________________________

Signed: _____________________________________________________

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Catholic Safety, Health & Welfare South Australia

ACCIDENT/INCIDENT/NEAR MISS REPORTING No. 2 Form 2b Version 3 Page 4 of 4

PART C
Has a Workers Compensation Form been lodged with your employer? Yes No NB Please ensure that your claim for compensation form is lodged with an accompanying Prescribed Medical Certificate from your certifying medical practitioner.
NATURE OF INJURY (Please tick box for principle Injury/Disease)
Fracture (excluding of vertebral column) Fracture of vertebral column with or without mention of spinal cord lesion Dislocations Sprains and strains of joints and adjacent muscles (including acute trauma sprains and strains only) Intracranial injury, including concussion Internal injury of chest, abdomen and pelvis Traumatic amputation, including enucleation of eye (loss of eyeball) Open wound not involving traumatic amputation Superficial injury Contusion with intact skin surface and crushing injury, excluding those with fracture Foreign body of external eye, in ear or nose or in respiratory, digestive or reproductive systems (including choking) Burns Injuries to nerves and spinal cord without evidence of spinal bone injury Poisoning and toxic effects of substances Effects of weather, exposure, air pressure and other external causes (including bends, drowning, electrocution) Multiple injuries (only to be used where no principal injury can be identified) Damage to artificial aids

NATURE OF DISEASE

Other and unspecified injuries Deafness Eye disorders (non-traumatic) Other diseases of the nervous system and sense organs Disorders of muscle, tendons and other soft tissues (includes synovitis, tenosynovitis, bursitis) Other diseases of the musculoskeletal system and connective tissue Dermatitis and other eczema Other diseases of the skin and subcutaneous tissue Hernia Other diseases of the digestive system Infectious and parasitic diseases Diseases of the respiratory system (including asthma, legionnaires disease, asbestosis, pneumoconiosis) Disease of the circulatory system (including heart disease, hypertension, hypotension, varicose veins) Cancers and other neoplasms Mental disorders Other diseases Deafness

BODILY LOCATION OF INJURY / DISEASE(Please tick box for principle body location of injury/disease) LEFT/RIGHT
Eye Ear Face Head (other than eye, ear and face) Neck Back Trunk (other than back and excluding internal organs)

LEFT/RIGHT
Shoulders and arms Hands and Fingers Hips and legs Feet and toes Internal Organs (located in the trunk) Multiple locations (more than one of the above) General and unspecified locations

MECHANISM OF INJURY / DISEASE

BREAKDOWN AGENCY/AND AGENCY OF INJURY/DISEASE

(Please tick box for principle mechanism and breakdown agency of injury/disease)
Falls from a height Falls on the same level (including trips and slips) Hitting objects with a part of the body Exposure to mechanical vibration Being hit by moving objects Exposure to sharp, sudden sound Long term exposure to sounds Exposure to variations in pressure (other than sound) Repetitive movement with low muscle loading Other muscular stress Contact with electricity Contact or exposure to heat and cold Exposure to radiation Single contact with chemical or substance (excludes insect or spider bites and stings) Long term contact with chemical or substance Other contact with chemical or substance (includes insect and spider bites and stings) Contact with, or exposure to, biological factors Exposure to mental stress factors Slide or cave-in Vehicle accident Other and multiple mechanisms of injury

Unspecified mechanisms of injury

Machinery and fixed plant Mobile plant Road transport Other transport Powered equipment, tools and appliances Non-powered hand tools Non-powered equipment Chemicals Non-metallic substances Other materials, substances or objects Outdoor environment Indoor environment Underground environment Live animals Non-living animals Human agencies Biological agencies Non-physical agencies Other agencies Unspecified agencies

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Catholic Safety, Health & Welfare South Australia

PARISH SECTOR
INCIDENT/ACCIDENT/NEAR MISS REPORTING
Sector Approved: 10 October 2010

Policy Reference:

No. 2

Form No: 2b
Page 1 of 1

Review Date: October 2013

FIRST AID REGISTER

Date Name of Injured Person Type of Injury and location of injury (eg cut, burn) First aid treatment given Signature Hazard Report Form completed
(if applicable) Yes / No

Hazard Register Updated

Dates report reviewed: .. By Whom: .

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