INVESTIGATION REPORT

SF 5.9.3A

Used in conjunction with Safety Report SF 5.14.1.A

Quality Report QA-01
Environmental Report ENV-01

NOTE: When investigating personal or property damage events, this report must be completed fully.
When investigating other events, complete only the sections relevant to that event.
The aim of this investigation is to find the cause of the event, not to place blame.

Anatomy of a Damaging Event

Phase 1 Phase 2 Phase 3 Phase 4 Phase 5 Phase 6 Phase 7 Phase 8
Development Process Metastable Unstable Damaging Recovery Repair Stable
of Conditions Starts Region Region Region Condition

The contributing All the The event The event will The extract Transfer to Injury / Return to
factors are contributing process has occur. part of event repair centre. Damage normal
starting to fall into factors are started but where energy corrected. operation.
place. now in place. can still be was
stopped. transferred.

Investigation Instructions.

Step Action
Step 1 Assemble the investigation team
Step 2 Complete the Chain of Events
Step 3 Complete as much of the report as possible before conducting interviews
Step 4 Decide on who needs to be interviewed and in what order.
Step 5 Conduct interviews
Step 6 Complete investigation and decide on Recommended Corrective Actions
Step 7 Place Report in distribution circuit

1. Date of Investigation:

1.1 Report Registration Number:

SAFETY
QUALITY
ENVIRONMENTAL

1.2 Investigation Team (Names only)

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1.3 Establishing the Chain of Events.

Pre-Investigation
The first step is to assemble the investigation team and look at just what the team is required to do. What
information/facts are already known? Who does the team need to interview? What data, documents, etc., does the
team need to examine. Start putting together the Chain of Events. After this has been completed, interviews can
start.

What we know What we dont know Answers

1.4 Use this area to draft up possible questions or prompts.

2. Investigation

2.1 What task was being carried out at time of event? (A full description is required)

2.2 If the event resulted in an injury or damage, detail exactly what the damaging event was. (What was the exact
cause of injury or damage and what was the energy involved?)

2.3 If this event involved a production process, collect all trend charts associated with the event and attach
them to this report

2.4 What other documentation does this investigation need to examine? List.

2.5 If the event did not result in an injury or damage, what is being investigated? (Identify the problem exactly)

2.6 Where else could this event have occurred, but has not?

2.7 What is the deviation? (What is different between these locations? What is the difference between objects?)

2.8 Who does this investigation need to interview? List. (Page 2 will assist in deciding these)

2.9 How Long has the person/s involved with QMAG? yearsmonths

2.10 How long has the person/s involved been doing this type of task? yearsmonths

2.11 Who witnessed the event?

2.12 Are their statements attached?

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2.13 Is the person/s involved statement attached?

2.14 Have photographs been taken of the scene or of the equipment involved?

If yes, are they properly identified and attached to this report?

2.15 Has an engineering plan of the event site been prepared?

If yes, has it been properly identified and attached to this report?

If no, sketch a plan of the location showing as much detail as necessary.

2.16If this event was of a serious nature or involved a vehicle, has the driver undertaken a alcohol and drug screen?
Yes No . If yes, what were the results: (Attach the test result sheet to this report)

POSITIVE NEGATIVE (Tick one box)

3. Contributing factors

Note 1: In establishing the contributing factors, questions asked will need to be worded in such a
way to determine: What did the people involved do that contributed to the event? What did
the people involved not do that contributed to the event? What was present that

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contributed to the event? What was not present that contributed to the event?
Note 2: Where it is appropriate the wearing and use of Personal Protective Equipment will need to
be established. This can be done under 3.1, 3.6, 3.8, 3.9, 3.11 and 3.12.

See Question List at back of this report.

3.1 Human. Skills, Knowledge, Attitude, Health, Control. (These can be identified from section 2.1 and by asking
additional questions). (List in this section if the persons involved had taken prescription or non-prescription drugs, or alcohol prior to the
event).

3.2 Machine. Design, Manufacture, Installation, Operation, Maintenance. (These can be identified from section 2.1
and by asking additional questions)

3.3 Environment. Process, Training, Location, Climate, Conditions. (These can be identified from section 2.1 and by
asking additional questions).

Click one tick box on each line to indicate the degree of effect of the environmental conditions existing at the time
of the accident.
Rain Nil Heavy
Wind Nil Strong
Dust Nil Heavy
Floor Conditions Dry Wet
Floor Conditions Even Uneven
Floor Conditions Smooth Rough
Noise Quiet Loud
Temperature Cold Hot
Fog Nil Thick
The red box on lines (where shown) indicates normal operating conditions.

3.4 If measurements were taken of any of these conditions, detail those measurements here.

3.5 What effect did the climate or conditions have on the event?

3.6 Did the person/s involved take any action to regain control or to reduce the
consequences either before the event or after the event, if so, what?

3.7 What instructions were given to the person/s involved before performing this task?

3.8 What training into the task has the person/s involved undertaken?

3.9 What Work Instructions, Safety & Health System Procedures, Quality Procedures or Environmental
Procedures, are written for the task?

3.10 Were these WIs or Procedures followed? If not, why not?

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3.11 Did the location of the event have an effect on the occurrence of the event or on the outcome of the event?
Explain. (Refer back to sections 2.6 and 2.7).

3.12 Has a Risk Assessment been previously conducted on this event? If yes, what are the implications for this
investigation?

3.13 Has this type of event occurred before? If yes, what are the implications for this investigation?

3.14 Other information of relevance to this investigation that needs to be considered.

4. Recommended Corrective action

Note: When determining corrective actions/s, keep in mind that it may be necessary to check for
compliance with QMAGs rules and procedures, health and safety legislation, Australian Standards, or for
wider implications across QMAGs operations. You will need to refer to the table on page 17 and address
Identify Possible Causes, Evaluate Possible Causes and Confirm True Cause.

4.1 What corrective action/s is/are recommended to eliminate or control this event?

4.2 Investigation Complete

Signature: Date:

(Team Leader)

4.3 This report is now to be sent to the Department Manager.

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5. Department Managers Action Plan

5.1 Action Action By Completion Date

5.2 Is a Risk Assessment required? YES NO (Circle one. If Yes, include in action plan)
Signature: Date:

(Department Manager)

5.3 This report is now to be sent to the General Manager Operations.

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Investigation Check Lists

Determining the Facts Establishing the Conclusions

Who What systems failed?

was injured or what was damaged? how can we prevent failure or make it less likely?
saw the event? how can we detect approaching failure?
was working with the injured/operator? how can we detect failure when it occurs?
had instructed and/or assigned the job to the injured operator? how can we control failure (minimise consequences)?
else was involved?
has information on events prior to the event?
What Which persons failed?
is the injury/damage/event? what did they do?
was the injured/operator doing? what did they fail to do?
had the injured/operator been instructed to do? how can we make failure less likely?
tools were being used? Were they for the job? Were they in a safe condition?
machinery/plant/equipment was in use? Was it used safely: If it involved a production process, have trend charts Which item of plant/equipment failed?
been checked? Were there warnings of pending problems? what was present that made it fail?
previous similar events have occurred? Check Safety Database. what was not present that made it fail?
did injured/operator or witnesses see? how can we make failure less likely?
safety rules were violated? Check Work Instructions and Safety Procedures?
safe systems of work, permits to work, isolation procedures were there; Has all documentation been collected and
examined:
training had been given: Does the training address all aspects of the task?
were the contributory causes of the accident? Have all been identified? There is always more than one.
what similar object(s) could reasonably have the
communication system was in use? deviation, but does not?
what specific object(s) has the deviation? what other deviations could reasonably be observed,
what is the specific deviation? but are not?
When What is the purpose of the persons actions?
did the event occur? why do we do this?
did the damage become evident?
did the injured/operator start work? Was fatigue a factor?
was an explanation of the hazards given? The importance of this increases with new/transferred people. when else could the deviation have been observed
did the supervisor last see the injured/operator? first, but was not?
when was the deviation observed first (in clock and calendar time)? when since that time could the deviation have been
observed, but was not?
when since that time has the deviation been observed?
when else, in the objects history or life cycle, could the
any pattern? deviation have been observed first, but was not?
when, in the objects history or life cycle, was the deviation observed first?
Why What could we do instead?
did the injury/damage occur? how else could we do it?
did communication fail? who else could do it?
was training not given? when else could it be done?
were unsafe conditions permitted?
was the hazard not evaluated:
was PPE not provided? This includes warning signs, barricades etc.
was PPE not used?
was there no safe system of work, permit to work or isolation procedure operating?
were specific safety instructions not given?
was injured/operator where he/she was?
was the supervisor not consulted when things started to go wrong?
was the supervisor not there at the time?
Where What specific items in the system triggered the accident?
did the event occur? what does it do? Why do we do this?
did the injury/damage occur? what could we do instead?
was the supervisor at the time? what could we use instead?
were the witnesses at the time? how else could we do it?
where is the object when the deviation is observed (geographically)? where else could the object be when the deviation is
where is the deviation on the object? observed, but is not?
where else could the deviation be located on the
object, but is not?
How
did the injury/damage occur? when corrective action is taken, how will results be
could the event have been avoided? checked?
could the injury/damage been avoided?
could the supervisor have prevented the accident?
could better design help?
Extent how many objects could have the deviation, but do
how many objects have the deviation? not?
what is the size of a single deviation? what other size could the deviation b, but is not?
how many deviations are on each object? how many deviations could there be on each object,
but are not?
what is the trend? (in the object?) (in the occurrences and size of the deviation?)
what could be the trend, but is not? (in the object?)
(in the occurrences and size of the deviation?)

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6. Distribution

Reception. Place this report into the distribution folder, attach the Distribution List to the front of this report and start
circulation.

6.1 General Manager Operations

Comments:

Signature: Date:
This report is now sent back to the Department Manager.

6.2 Department Manager

Comments:

A copy of pages . is now sent to the Action Officer/s listed in 5.1 above. If more than 1 Action Officer, individual
copies to each. After the Action Plan items have been completed, sign off the section.
Signature: Date:

If this event involved damage exceeding $5000, this report is sent to the Commercial Manager. If not, it is now sent to the
General Manager QMAG.

6.3 Commercial Manager

Comments:

Signature: Date:

This reports is now sent to the General Manager QMAG.

6.4 QMAG General Manager.

Comments:

Signature: Date:

This report is now sent to CEO AMC.

6.5 AMC CEO.

Comments:

Signature: Date

6.6 This report is now returned to QMAGs Safety Manager for filing.

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