Incident Report Form (Non Injury) - T-1039

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Incident Report Form (Non Injury) - T-1039 Powered By Docstoc
					                                                    TARONG ENERGY CORPORATION LIMITED                                        Generating
                                                                                                                             Safety
                                                   HSE Incident Report Form                                                  Together



Use this form for ALL significant environmental and/or near miss, property and equipment damage incidents. The form may also be used to
report concerns and public complaints. Immediately report HSE Incidents to your supervisor; copy report to the HSE team within 24 hours;
high and extreme risk incidents must also be copied to the relevant GM.

               Remember: Take immediate temporary control to minimise the impact of the incident.
                                          Classification of Incident (Type and Details)
Brief Title:                                                                                                             No.:

     Potential Incident (eg, near miss)               Property Damage                        PTW Incident                Motor Vehicle

     Environmental Incident                           Environmental Complaint                            HSE Concern                      Fire

Reported by:                                                             Responsible Supervisor:
Incident Location:                                                                                               Site:

Date & time incident occurred:                                           Date & time incident reported:

                                     Description of Incident / Potential Incident




Procedure or JSEA used?                No       Yes …Details:
Describe the sequence of events that led to the incident (attach notes/plans/photos as appropriate):
1)
2)
3)
4)
5)
6)
7)
                                                                                                          Attachments (photos etc)

                                                                  Hazard Agency
     Electrical (shock, failure)                          Objects Falling                               Windblown Dust etc.
     Machinery (plant, mechanical)                        Thermal (hot pipes etc.)                      Welding (Slag, Flash etc.)
     Non- standard procedure                              Fumes/Chemicals                               Natural Event
     Work environment                                     Fire
     Other (specify):
                                         Nature of Environmental Impacts (If relevant)
  Air / Dust /            Pests or            Noise /              Water                Oil / chemical /            Unauthorised
Odour Event             Weeds               Vibration            Contamination       fuel / solvent              vegetation disturbance
     Fauna Impact          Cultural heritage site                   Land Contamination                              Inappropriate waste
                        impact                                                                                   disposal / management
     Other (specify):

                                                       Environmental Complaint
                        (The incident classification, description and follow-up actions sections must also be filled out).
Type of Communication:                 Letter                       Phone                       Verbal                           Email

Name of Complainant:                                                                         Contact details:

Reported to:                                                                                 Reported by:



                                                                                                                      Form No. T-1039 (07/07)
                                     All incidents can be prevented through effective job planning                                 Page 1 of 3
                                                    TARONG ENERGY CORPORATION LIMITED                                     Generating
                                                                                                                         Safety
                                                    HSE Incident Report Form                                              Together




                                    Risk Assessment/ Notification Requirements
                               (This section is filled out by Supervisors with assistance from H&S/E Officers)
Actual Incident Consequence (refer Step 1 of Risk Matrix below)
       Insignificant                     Minor                Moderate                  Major               Catastrophic
Potential or Inherent Risk (Use Risk Matrix below)
        Negligible                       Low                    Moderate                High                Extreme

Criteria for Investigation:
The ICAM Analysis Form (T-1351) can be used at any time. However, if the Potential Risk is Moderate, it must be filled out
and attached to this report form.
If the Actual Incident Consequence is Moderate or higher, OR if the Potential Risk is High or Extreme, a formal incident
investigation is required and Form T-1081 must be completed.

Safety Incident Classification (consult with OHS Department re: dangerous events or serious injuries/ illnesses)
       Dangerous Event                   Serious Bodily Injury            Critical Incident (H / E)         Notable Incident (M)

                                     Step 1 Determine Consequences                                          Step 2. Determine Likelihood
          To People                      Property                        Environment                               Event Frequency
                                         Damage
     5                Fatality(s)        >$5M              serious environmental harm (actual or                     Almost Certain.
                  or permanent         damage           potential); impacts that are irreversible,          A    Occurs in most
Catastrophic
                  disability(s)                         widespread or of high impact; likely penalty;            circumstances; or certain
     4                Serious LTI        $500k-            Environment harm (actual or potential);                   Likely. Likely to occur;
                                                                                                            B
   Major          or illness           $5m damage       temporary or permanent – reportable to EPA.
     3               Lost time,           $50k-            Direct or indirect environmental impact                  Occasionally. Might
                                                                                                            C
  Moderate        Alternate duty       $500k damage     beyond incident site (on or offsite).                    occur;
     2               Medical              $5k - $50k       Localised & isolated environmental impact.               Unlikely. Could occur,
   Minor          Treatment            damage                                                               D    but unlikely

      1               No or minor        < $5k             Localised event of little environmental value.            Rare In exceptional
                                                                                                            E
Insignificant     first aid            damage                                                                    circumstances

                                                          Risk Assessment Matrix
                                                       Step 3. Calculate Risk Ranking

                                         1                  2                 3                    4                   5
                                   Insignificant          Minor            Moderate               Major           Catastrophic

              A
                                    Moderate            Moderate              High               Extreme            Extreme
         Almost Certain
                  B
                                       Low              Moderate           Moderate                  High           Extreme
                Likely
               C
                                       Low                Low              Moderate                  High             High
          Occasionally
                D
                                    Negligible            Low                 Low               Moderate              High
             Unlikely
                 E
                                    Negligible          Negligible            Low               Moderate           Moderate
                Rare


Sketch of incident scene (as required)                                      Photos / Drawings attached: Yes                      No
                                                                                                                                           N




                                                                                                                   Form No. T-1039 (07/07)
                                      All incidents can be prevented through effective job planning                             Page 2 of 3
                                                TARONG ENERGY CORPORATION LIMITED                            Generating
                                                                                                             Safety
                                               HSE Incident Report Form                                      Together




                                             Supervisor’s/ Manager’s Actions :
Immediate action taken to control hazard / incident                                                                  Work Order




                        List Causes / Contributing Factors and Additional Comments (if necessary)
People
Environment
Equipment
Procedures
Organisation

Refer to ICAM pocket
invest guide & attach
PEEPO chart/ ICAM
analysis as required.


                Follow Up Actions: (if required – eg investigation, engineering fix, training, procedures)
Action Required                                                                  By Whom           By When           WO Number




                                    Sign Off (where appropriate)                                                 Date
Person/s involved                                                                                                /        /

Supervisor                                                                                                       /        /

Coordinator                                                                                                      /        /

Health & Safety Department                                                                                       /        /

Environment Department                                                                                           /        /

Manager Operations                                                                                               /        /

Chief Operating Officer (for high risk)                                                                          /        /

Does this incident require further investigation?                         No        Yes…if Yes, complete T-1081


                                                                                                      Form No. T-1039 (07/07)
                                   All incidents can be prevented through effective job planning                   Page 3 of 3