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					                         Catholic Safety Health & Welfare SA



           ACCIDENT / INCIDENT / NEAR MISS REPORT FORM

                                   INSTRUCTIONS                                          NOTIFICATION OF CERTAIN WORK RELATED
                                                                                         INJURIES AND DANGEROUS OCCURRENCES
              This form is to be used to report all incidents and                             OHS&W Regulations 1995 Pt 6 Div. 6.6
accidents including near misses.                                                                Notification of Certain Occurrences
All occurrences must be reported to your immediate                            Any injury resulting in death or requiring treatment as an in-patient in a
supervisor/manager as soon as practicable and within 24hrs.                   hospital, acute symptoms associated with exposure to a substance.
                                                                              Dangerous occurrences – Electrical short circuit, malfunction or
Page 1 –           To be completed by person reporting the incident.          explosion, uncontrolled explosion, fire or escape of gas, hazardous
                                                                              substance or steam.
Part A –           To be completed by the injured person or another
                   person on behalf of the injured person.
                                                                              Reason for notification: Admisson as an in-patient
Part B –           To be completed by the Manager/Supervisor in
                                                                              Have you contacted your OHS Consultant?                Yes  No
                   consultation with ALL affected parties.
                                                                              NOTE: CSH&W after hours ph 0438396062
Part C –          Completed in the case of a sustained injury by either
                                                                              Has SafeWork SA been notified within 24 hrs?           Yes  No
                  the person involved and/or the person conducting the
                                                                              SafeWork SA contact No: 1800 777 209
                  investigation.
If a claim is to be lodged please forward a copy of the full report to CCI    Ref no._______________
within 3 working days from the date of the injury.


WORKSITE: The Catholic Youth Camp
ADDRESS Black Stump Rd, Middleton, SA
SITE CONTACT PERSON: Simon Henry
PHONE: 8539 6572                                                                    EMAIL: shenry@cyc.org.au



                                                        SUMMARY OF INCIDENT
Incident resulted in:                                                  Position of person involved/injured:
 No Injury/Near Miss          Injury (lost time)                      Employee                              Self-employed
 Damage to property           Exacerbation of previous Injury         Visitor                               Contractor

 Injury (No lost time)                                                 Volunteer                             Other __________________________

Date of Incident        01/12/2008                                           Time of Incident                 09:00                           AM/PM
Date Reported           01/12/2008                                           Time Reported                    09:30                           AM/PM
Reported to             Simon Henry
Describe briefly what happened:
Kevin was in the workshop using a nail gun to put together a shelving unit. During the process Kevin took his safety glasses off and
accidently pulled the trigger of the nail gun. The nail ricocheted and hit Kevin in the eye. The nail lodged in Kevin’s eye




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  Review Date: January 2010
                  Catholic Safety Health & Welfare SA


                                                                                                                    PART A
NAME OF PERSON INJURED/INVOLVED:

Milligan                                          Kevin David
Surname                                          Given Name/s

Age Group                                                                        Gender (M / F)        
                 <20    20-29   30-39    40-49    50-59   60-79   80+                                    M      F

Occupation/Job Title Maintenance Officer

Contact Phone No. (Wk) 8539 6572         (Hm) 8545 1234             (Mob) 0499 192 090

Home Address 16 Long Street, Goolwa, SA

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

Griggs                                           Mary Rose
Surname                                          Given Name/s

Contact Phone No.(Wk) 8539 6572          (Hm) 8545 9876            (Mob) 0435 154 789

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

Novak                                            Barry Roy
Surname                                          Given Name/s

Contact Phone No. (Wk) 8539 6572           (Hm) 8571 9024         (Mob) 0467 254 601

 _____________________________________________________________________________________________________________
Surname                                Given Name/s

Contact Phone No. (Wk)_________________ (Hm) _______________ (Mob) _______________

                                                                                                                    PART B
INCIDENT/ INVESTIGATION DETAILS: add additional pages and photographs as required

Date on which investigation commenced:     02 / 12 / 2008
EXACT LOCATION OF INCIDENT: eg. Particular building/room, while in transit (vehicle etc)

The workshop behind the main administration building.

EXPLAIN THE WORK/ACTIVITY BEING UNDERTAKEN AT THE TIME OF INCIDENT: Identify any
plant/substance/equipment involved

Construction of a shelving unit.

WHAT HAPPENED? Please include a description of events:

A wooden shelving unit was purchased on the 27th of November 2008. It was a modular unit that required glueing and nailing.
As the site has a pneumatic nailgun it was decided that the use of the nailgun would be more effective and quicker. Kevin and
Barry unpacked the carton containing the timber parts that made up the shelving unit. Kevin used the nailgun while Barry held
the timber parts of the unit in place. Both Kevin and Barry were wearing safety glasses.

During the construction of the unit Kevin took off his safety glasses (due to them being scratched) to look at one of the nails he
had just inserted into the unit to ensure that the nail had gone in properly. During the time Kevin had removed his safety
glasses he accidently touched the trigger of the nailgun which sent a nail to the cement floor of the workshop. The nail
ricocheted off the cement floor and lodged in his left eye.
A pressure bandage was placed around the injury site and Kevin was rushed to the Victor Harbour Hospital, where he was
transported by ambulance to the Royal Adelaide.




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Review Date: January 2010
                   Catholic Safety Health & Welfare SA

WHAT FACTORS CONTRIBUTED TO THE INCIDENT?
People: (eg culture, language, fatigue?) Kevin was experienced in the use of the nailgun and has used nailguns in his previous
employment in the construction industry.


Total hours worked when incident occurred: 1 hr


Environment: (eg lighting, temperature, wind?) There is adequate lighting in the workshop and a light meter reading of 1500 lux
was performed on the 17th of July 2006. There has been no change to the lighting since that date. Light is provided by both
natural (via skylights) and artificial.


Plant/Equipment: (eg guarding, maintenance, type of plant/equipment?) Ryobi SX 300 nailgun using 40mm nails and an Acme
100psi air compressor.


Materials: (eg suitable for task, clothing, footwear, personal protective equipment, materials used?) Both Kevin and Barry were
wearing their issued overalls, ear protection, safety glasses and safety boots. Kevin’s safety glasses were scratched which
made visibility difficult.


Procedure/Job/Task: (eg appropriate procedure, task organisation, training, SOP’s, supervision?)
         No risk assessment was performed on this task.
         There is in place a prepurchase risk assessment for thre nailgun.
         A safe operating procedure (SOP) has been produced for the use of the nailgun and is kept in the nailgun case.
         Kevin’s safety glasses have been scratched over time and made it difficult to perform close examinations.
         Personal protective equipment (PPE) has not been placed on the maintenance register.



LIST ACTIONS TO PREVENT REOCCURRENCE Manager/Supervisor should complete in consultation with the H&S Rep
where appointed and those involved.


Immediate Action Taken – Ensure that all PPE is checked and any faulty items replaced.


Interim Controls: (Short Term)
         Ensure all tasks are risk assessed by the supervisor and employee involved with the task.
         Ensure PPE is placed on the maintenance schedule and is checked as per the manufactures recommendations or
          every six months.
         Encourage employees to report damaged PPE immediately.




Proposed Permanent Controls –
         Review the risk assessment for the nailgun.
         Perform risk assessments for all the tasks that require the use of the nail gun and use the Hyrachy of Control to
          implement appropriate controls. Where possible select suitable controls that will eliminate the use of the nailgun such
          as the purchase of pre-assembled furniture/shelving, liquid nails, screws, dowels etc.
         Review the SOP for the nailgun and ensure the inclusion of the removal of safety glasses is prohibited.
         Remind employees of their responsibilities to their own health and safety in using PPE.




Action plan/Hazard Register updated      Yes      No    Ref No 08 024 Risk Assessment Ref No CYC 015

         USE HIERARCHY OF CONTROLS in descending order:




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Review Date: January 2010                                                                                                           3
                     Catholic Safety Health & Welfare SA

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




    Has feedback been provided to person/s involved in the incident:  Yes Date: 05 / 12 / 08  No




    SUPERVISOR / MANAGER – I confirm the details of the incident reported and agree with the recommendations made.

Name: Brenton Hansford ____________________ Date:             05 / 12     / 08       Ph: 8539 6572          ____________________

Signed: _______________________________________________

Name of person Investigating incident: Brenton Hansford _____                    Comments: This incident has highlighted
                                                                                 gaps in our Safety Management System
Signature: _______________________ Date:            05    / 12     / 08          which requires urgent attention.


Name of Health and Safety Representative: N/A _____________                      Comments:

Signature: _______________________ Date:                  /        /

                                                                                                                  SIGN OFF




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    Review Date: January 2010                                                                                                      4
                               Catholic Safety Health & Welfare SA
                                                                                                                                    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/ DISEASE / DISORDER
            Asbestosis, Mesothelioma, Silicosis                                             Injuries to nerves & spinal cord
            Asthma including bronchitis                                                     Internal injury of chest, abdomen and pelvis
            Burns and scalds                                                                Intestinal infectious and parasitic diseases
            Contact dermatitis                                                              Intercranial injury, (eg. concussion, etc)
            Contusion with skin and crushing injury, excluding fracture                     Legionnaires disease
                                                                                             Malignant Melanoma
            Damage to artificial aids                                                       Mental Disorders
            Deafness                                                                        Multiple injuries
            Disease Circulatory system (incl heart disease, hypertension, etc)              Open Wound (eg. cuts, laceration, etc)
            Disease Brain, spinal cord and peripheral nervous system                        Other and unspecified injuries (stabbing)
            Disease Skin (eg. contact dermatitis, malignant melanoma, etc)                  Other and unspecified diseases
            Dislocation                                                                     Poisoning / toxic effects
            Disease Eye (incl conjunctiva and cornea)                                       Respiratory condition due to substance
            Disorder of the nerve roots, plexuses and single nerves                         Sexually transmitted disease

            Disorder of the musculoskeletal system (inch joints, spine, disks,              Sprains & Strains of joints & muscles
             soft tissue, etc)                                                               Superficial injury (egg. Cuts and lacerations)
            Effects of weather, exposure, pressure (includes ‘bends’)                       Traumatic amputation (including loss of eyeball)
            Foreign body (in eye, respiratory or digestive system, etc)                     Ulcers & gastritis
            Fracture                                                                        Varicose Veins
            Heart Disease                                                                   Viral Disease
            Hernia                                                                          Viral Hepatitis
            Hepatitis or HIV (AIDS)
                                BODILY LOCATION OF INJURY (Please tick box for principle body location of injury)
                                             LEFT/RIGHT                                        LEFT/RIGHT        Systemic Locations
          Abdomen                                                 Large Intestine                                  Circulatory System
          Ankle                                                   Leg/lower limb                                   Digestive System
          Back                                                    Liver                                            Nervous System
          Bladder                                                 Low Back
          Brain                                                   Lung
          Breast/Larynx, Oesophagus                               Mouth
          Chest                                    Neck                                                             Psychological System
          Ear                                      Nose                                                             Respiratory System
          Elbow                                                   Other internal organs
          Eye/Eyeball/Eyebrow                                     Pancreas
Face                                                               Pelvis                                       Multiple Locations
          Fingers                                                 Ribs                                             Eyes & Ears
          Foot                                                    Shoulder                                         Foot and toes
          Forearm                                                 Small Intestine                                  Hand, Fingers and Thumb
          Gallbladder                                             Spleen                                           Head & Neck
          Genital organs                           Stomach                                                          Neck and shoulders
          Groin                                                   Trunk Upper and lower                            Neck & Spine
          Hand                                                     limbs                                            Neck and trunk
          Head/Skull                                              Upper arm
          Heart                                                   Upper Back
          Hip                                                     Upper leg                                        Other specified multiple locations
          Kidney                                                  Upper limb
          Knee                                                    Toes
                                                    Wrist
                              CAUSE / MECHANISM OF INCIDENT (Please tick box for principle mechanism of injury)
            Being assaulted by a person                                              Harassment
            Being bitten by animal                                                   Hitting moving objects
            Being hit by person accidentally                                         Hitting stationary objects
            Being hit by an animal                                                   Insect, spider bites / stings, etc
            Being hit by falling objects                                             Long-term contact with a chemical or substance
            Being hit by moving objects (can inch cutting yourself, etc)             Long-term exposure to sounds
            Biological factors (including infectious disease)                        Muscular stress - no specific incident (no objects being handled)
            Contact with cold objects                                                Muscular stress - lifting, carrying, pushing, pulling, lowering
            Contact with hot objects                                                 Muscular stress – bending, twisting, reaching
            Contact with electricity                                                 Muscular stress - Repetitive movement
            Exposure to blood, body fluid, needle stick / sharps injury              Mental Stress factors
            Exposure to ionising radiation (egg. x-ray, etc)                         Rubbing & chafing
            Exposure to non-ionising radiation (egg. sunburn)                        Single contact with a chemical or substance
            Exposure to occupational violence                                        Slide or cave-in
            Exposure to traumatic event                                              Suicide or attempted suicide
            Exposure to environmental heat/cold                                      Trapped between stationary & moving objects
            Exposure to mechanical vibration                                         Trapped by moving machinery
            Exposure to single, sudden sound                                         Unspecified cause / mechanism of injury
            Falls from a height                                                      Vehicle Accident
            Fall on the same level (egg. slip or trip)                               Work pressure
                                                                                      Workplace harassment or bullying


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           Review Date: January 2010                                                                                                                   5

				
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