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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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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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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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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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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