Appendix 2: Incident report

Incident report

Note: All sections of this form are to be completed. All incidents shall be advised within 12 hours of the incident
to ensure appropriate action is initiated.

Personal details

Family name: Laurie First name: Jonhs

Contact Phone No: 02 03429908 (h –if injured) injured

Occupation: senior administrator Gender:  M  F

Staff employment status:

 Full-time  Part-time  Casual

 Contractor  Visitor

Division/Department: Administration

Incident details
Date of incident:29/03/2017 Time of incident: 3.40pm PM

Location where incident occurred: Main Office

Briefly describe what happened: Rosie tripped on one of the computer cables fell on the floor and sprained
her wrist.
This incident resulted in:

 Injury  No injury  Near miss

 Property damage  Hazard identified

The incident was reported to (Supervisor): Yes

Name of Supervisor: Mr Jason wright Date 29/03/2017

Injury/damage details

If an injury was sustained, what part of the body was affected; or if damage to property occurred, what was
damaged?

Injury sustained to the right hand wrist

No property damage was incurred

Medical treatment

If MEDICAL EXPENSES or LOST TIME is incurred, a Workers Compensation Claim form must be completed
and forwarded to WHSW & IM Services as soon as possible.

Do you intend to seek medical treatment?  Yes  No

Do you intend to lodge a claim for workers compensation?  Yes  No

Has any time been lost from work?

 Yes  No
(More than 1 complete shift)

If so, have you returned to work?  Yes  No

Have medical expenses been incurred/will medical expenses be  Yes  No

 incurred?  Uncertain at this time

Were there witnesses? Witness(es) contact phone number:

If so, provide name of witness(es):
0450203205
Yes one Witness the supervisor Jason Wright

Employee signature: J wright Date:29/03/2017

If a medical certificate has been provided please send to: Fax 026307251 or email: jw@admin office .com.au

Describe in detail what occurred

It is the responsibility of the supervisor/line manager to complete this section in consultation with the injured
staff member.

Please describe the events and contributing factors that led to the incident:

Rapid growth in the company led to many new computers being installed and the power extension cables
became loose and were lying on the floor of the hallway and office. There have been a number of near misses
(near accidents) with many employees.

How could this be prevented from happening again? YES

The supervisor/line manager is to complete this section in consultation with the injured staff member and the
health and safety representative (if applicable).

Suggestions to avoid recurrence of this incident/accident:

Install many new power points in close proximity to the computers to avoid any loose cables.

Name of health and safety representative, if consulted: Michael Moose

Action plan
Note: From the previous section, list the actions required to prevent this happening again.

Action to prevent recurrence Person responsible Action Sign-off completed

(Do not leave blank) for action taken (signature required)
Remove current cables IT installer Cables removed Bruce Willis

Install multiple power points Electrician New Power points Gary Bender
and wiring
installed

 Referred to line manager  Placed issue on local action plan

 Consulted employees  Advised senior manager

 Advised WHSW Services  CSR raised, referred to FMU

 Feedback provided to affected person on outcome

Is rehabilitation required?  Rehabilitation consultant advised NA

 Yes Date:29/03/2017

 No

Name of Supervisor: Jason Wright Contact Phone Number: 9262588

Signed: J Wright Date: 29/03/2017

Appendix 3: Analyse data

The workplace incident data for the past three months is recorded in the incident register below. Summarise
the data in the graph provided and identify the areas that you should concentrate your improvement efforts on.

Incident Cause Type Who When

Slip/trip Cables on floor MTI Bob 13/07

Muscle pull Lifting paper MTI Jane 18/07

Muscle pull Moving bins FAI Nihal 30/08

 Bullying Project deadline LTI Laszlo 15/09

Stress Project deadline LTI Greg 17/09

Slip/trip Cables on floor NMI Bob 01/10

Cut Cut finger on broken glass FAI Rita 02/10

FAI first aid incidents

MTI medical treatment injury

LTI lost time injury

LTIFR lost time injury frequency rate

NM near miss

workplace data
2.5

1.5
Number
of
Incidents 1

0.5

0
MTI LTI FAI NMI LTIFR

Incident
INCIDENTS
Analyse the data above and suggest what you will need to focus on during the safety action meeting.

Based On the data above there was one near miss for a fall for an employee, however there were two falls
that resulted in first aid treatment and two due to lost time .

Safety action required is training on how to lift properly to prevent pulled muscles by Jane and Nihal. Trolleys
to move bins may also be required or bins on wheels.

Removal of cables with added power points to prevent fall , near misses by Bob.

Both of the actions above require re- engineering of the premises and retraining of employees which an
administrative control

Lastly two employees Laszlo and Greg had time off work due to stress/ bullying as a result of meeting tight
deadlines.

There are two solutions employ more staff to complete the work or extend the deadlines to reduce the stress.
Both of these are classified as administrative controls

Hierarchy Of Controls to be used for safety

1. Eliminate the hazard
2. Substitute or modify the hazard
3. Isolate the hazard
4. Use engineering controls
5. Use administrative controls
6. Introduce personal protective equipment (PPE)
Appendix 4: Safety inspection form

Criteria N/A Yes No Comments

EMERGENCY PROCEDURES Yes

Are designated emergency persons’ details posted, Yes John Smith
including:
Mary Parth
● health and safety representative
John Brown
● fire warden

● first aid person?

Are instructions posted for calling emergency services? Yes Corridor Wall

Is the site plan on display? Yes Corridor Wall

Are emergency evacuation muster/assembly areas Yes Yes opposite 118 Walker st
signposted?

Have all staff been inducted and trained in emergency Yes Induction
procedures?

Are entry and exit doors marked and free of clutter? Yes All elevators freely available

Are emergency exit routes and aisles and corridors free Yes No Blockage to stairwells
of clutter?

Are fire extinguishers provided and maintained? Yes Available in Kitchen

Have personnel onsite been trained in the use of fire Yes Firewarden on floor trained
extinguishers?

Are first aid kit/s stocked to contents list? Yes First Aid room

Are first aid supplies replenished? No Kit has yet to be used

HOUSEKEEPING
Is the bathroom and toilet clean and tidy? Yes No paper on the floor

Is the kitchen and eating area clean and tidy? Yes No water on the floor

Are floors clean, dry and in good condition? Yes All carpet is smooth no tears

Are desks and work areas tidy? Yes Computers are removed daily

Are rubbish bins sufficient? Yes 2 Bins

Is rubbish cleared regularly? Yes Twice a week

Are recycling bins sufficient? Yes Plastic and paper recycling

Are recycling bins cleared regularly? Yes Separate work station room

Are aisles and areas around workstations free of clutter? Yes Yes all materials in cupboards
Criteria N/A Yes No Comments

ERGONOMICS
Is furniture fit for purpose? Yes Office furniture new

Do office chairs have five supports? NA Some chairs have 4 feet

Is furniture adjustable for keyboard operators? Yes  straight back

 forearms parallel to the floor
● straight back
 upper legs parallel to the floor
● forearms parallel to the floor
● upper legs parallel to the floor
Are footrests provided where necessary? Yes Provided for permanent staff

Are document supports provided? Yes On company Intranet

Are computer screens positioned to avoid glare? NA Not required

Are workstations and equipment positioned to: Yes  reduce manual handling
 reduce repetitive handling
● reduce manual handling
 improve work flow?
● reduce repetitive handling
● improve work flow?

HAZARDOUS SUBSTANCES
Are all chemicals, including liquid fuels, properly NA Not relevant to office workplace
labelled, stored and signposted?

Are spill kits available? NA Not relevant to office workplace

Are MSDS readily available for hazardous substances? NA Not relevant to office workplace

Is a hazardous materials register maintained? NA Not relevant to office workplace

PPE (for hazardous areas)

Is safety signage accurate? NA Not relevant to office workplace

Is safety signage displayed correctly? NA Not relevant to office workplace

Are safety glasses worn when required? NA Not relevant to office workplace

Is high-visibility clothing provided where required? NA Not relevant to office workplace

OTHER
Appendix 5: SAM record form

Work safety team: names

Meeting held on: 5th April 2017

Meeting conducted by (supervisor): Bruna Denardi

HSR in attendance: Yes

Issues to be covered: Death of two workers on work site

At about 3:40pm, D'Alessandro was in charge of two workers in the pit and to manually assist the correct
positioning of the fourth wall as it was lowered into position.
The only means of entrance and egress was a steel ladder to the top of one of the walls (panel 2).
The pit was only slightly larger than the box made by the walls and the workers had no means of escape other
than the ladder.
Panel 2 began to fall forward and the two workers managed to scale the ladder on that wall and ride down and
jumped onto its back as it fell.
The failure of this wall caused another wall (panel 1) to immediately fall forward as it was no longer supported.
The two workers were unable to escape the second wall falling and were crushed to death in between the two
panels.

....................................................................................................................................................................

....................................................................................................................................................................

Other issues addressed: ..............................................................................................................................

 Lack of Quality checks on completed

 Lack of Work procedures
 Lack of safety work equipment
 Lack of WHS training

....................................................................................................................................................................

Staff in attendance: ....................................................................................................................................

WHS Officer

 Human Resources Manager

 CEO
 Supervisor
 Worksite Employees

Outcomes: ..................................................................................................................................................

 Drafted new Quality checks to be conducted on site against specifications

 New Work procedures drafted and approved for use after on the job training
 New safety work equipment purchased and training conducted on the use
 WHS training conducted by the WHS representative and Worksafe Queensland

....................................................................................................................................................................

....................................................................................................................................................................
Attendees:

Name: .............................................................................. Signature: .........................................................

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Name: .............................................................................. Signature: .......................................................

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