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WHS Incident and Investigation Procedure

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Section 1 - Preamble

(1) Charles Darwin University (‘the University’, ‘CDU’) is committed to fostering a safe workplace and learning environment through the management of work health and safety incidents and their subsequent investigation.

(2) The University’s objective in all incident investigation is to determine the cause(s) and contributing factors of an incident so that corrective/preventative actions can be developed and implemented to manage the risk and reduce the likelihood of recurrence. 

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Section 2 - Purpose

(3) This procedure provides the framework for incident notification, reporting, classification and investigation for all University campuses and facilities in accordance with relevant Work, Health and Safety legislation. This ensures all Work Health and Safety (WHS) incidents including near misses are reported, recorded and sufficiently investigated to produce appropriate corrective actions to minimise the chance of repeat incidents.

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Section 3 - Scope

(4) This procedure applies to all workers, as defined by the Work Health and Safety (National Uniform Legislation) Act 2011 including higher degree by research candidates and affiliates, who undertake any activities on University premises, or who execute work for or on behalf of the University either on or off campus and:

  1. are involved in a health and safety incident ; and/or
  2. sustain an injury or illness; and/or
  3. are subjected to a near miss.

(5) This procedure does not pertain to a member of the public who suffers a medical event that occurs whilst participating in clinical activities, unless the facility or equipment was a contributing factor. For further clarification on this contact Work, Health and Safety.

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Section 4 - Procedure

Immediate incident response

(6) Immediately following an incident, the first responder shall organise and arrange for the implementation of any measures required to:

  1. make the incident scene safe;
  2. initiate an emergency response or medical treatment (as required);
  3. notify relevant personnel;
  4. for notifiable incidents prevent escalation and preserve incident scene as per the REACT Protocol (Appendix 1); and
  5. report incident details.

Incident notification

(7) All workplace incidents are to be reported to the relevant supervisor/manager and an Accident, Incident and Injury Report (AIIR) completed. If the incident is classified, or has the potential of becoming classified, as extreme, major or notifiable notification and reporting of incidents must occur as set out in Table 1.

  1. Verbal notification to Work, Health and Safety should occur immediately to determine whether immediate notification to the relevant regulator/s is required.
  2. All written notifications are also to be sent to Work, Health and Safety as soon as reasonably practicable within 24hours.
  3. Refer to the Incident Notification Flowchart (Appendix 2) and Incident Management Flowchart (Appendix 3).

Table 1: Incident notification timeframes and responsibilities 

Incident classification Internal notification Person/position Notifying responsibility
Extreme / Major / External regulatory notification
Immediate, within 1 hour of incident.
External - potential for emergency services, EPA or WorkSafe involvement.
Regulator - immediate verbal notification required; followed by written notification within 24 hours of incident (NT WorkSafe).
Work area manager Vice-Chancellor and Pro-Vice Chancellors, Directors, Deputy CEOs and Managers, Senior Manager Work Health and Safety; and Emergency Response – Vice-President Governance and University Secretary, as required.
Vice-Chancellor and/or Pro-Vice Chancellors, Directors, Deputy CEOs and Managers or Director University Council and Vice-Chancellor's Advisory Committee; and University Senior Legal Officer.
Senior Manager Work Health and Safety Work, Health and Safety; External: regulators, legal etc; University Council, Vice-Chancellor's Advisory Committee (via monthly and bi-monthly reporting); and Subject Matter Expert to advise on incident (as required).
Moderate As soon as reasonably practicable or within 24 hours of the incident. Person reporting the incident Work area senior manager, Work, Health and Safety.
Minor and insignificant As soon as reasonably practicable or within 24 hours of the incident. Person reporting the incident Work area senior manager, Work, Health and Safety.

Incident classification

(8) The level of investigation classification will be determined by applying the guidance in Table 2. As an example, an incident classified as Extreme or Major would require a formal Incident Cause Analysis Method (ICAM) investigation.

(9) The work area where an incident occurred shall manage the incident through to completion with the support of Work, Health and Safety. The Senior Manager Work Health and Safety is the final authority for the classification of an incident or hazard.

Table 2: Incident classification and corresponding investigation level

Incident Classification WHS Impact Investigation Level
Extreme Multiple or single fatality; and/or
Irreversible health damage without loss of life; or
More than one person seriously injured.
ICAM Investigation
Regulator or Legal exposure
Major LTI >1 week;
Multiple / single major injury;
Permanent (full or partial) disabling injury;
Workplace modifications required.
ICAM Investigation
Regulator or Legal exposure
Moderate LTI <1 week (staff only);
Temporary (full or partial) disabling injury or health effect;
Injury that temporarily alters a person’s future;
Suitable duties in accord with injury management guidance;
Hazard which could result in harm to persons or damage to equipment.
ICAM dependent on the nature of the incident
Minor and Insignificant Medical Treatment Injury;
First Aid treatment;
Short-term inconvenience;
Near Miss.
AIIR form

Reporting and recording of incidents

(10) Incident reporting is required to:

  1. ensure notification to external or legislative authorities within applicable timeframes (where required by legislation);
  2. ensure appropriate emergency response is actioned (where necessary);
  3. ensure appropriate levels of the University’s management and staff are informed of the incident’s basic details in a timely manner (refer Table 1);
  4. preserve evidence and secure the incident scene;
  5. assist in identification of a risk or hazard that requires attention due to having the potential to cause harm; and
  6. ensure incidents are recorded and classified by Work, Health and Safety.

(11) A supervisor/manager receiving an incident report must make appropriate arrangements for the details of the incident to be recorded on the AIIR and sent to Work, Health and Safety either:

  1. during normal working hours, Monday to Friday;
  2. by close of business on the day of occurrence; or
  3. outside of these hours by midday the next normal working day.

(12) The responsible work area representative shall review the incident as soon as possible after receipt of notification.

(13) All incident information collected, including records of notifiable incidents, are to be recorded in accordance with the Records and Information Management Policy and Procedure; and are protected for access by authorised personnel only, including but not limited to:

  1. All investigation reports including preliminary assessments;
  2. Remedial / corrective actions;
  3. Witness statements;
  4. Relevant Risk Assessments;
  5. Incident photographs;
  6. Permits, Authorisations, etc; and
  7. Any other evidence collected.

(14) Regardless of classification, all incidents must be reported to the delegated Senior University representative and Work, Health and Safety. All incidents that are notifiable to a regulator (EPA, NT WorkSafe etc.) will also be reportable to University Council and Vice-Chancellor's Advisory Committee.

Investigation

(15) The objective of all incident investigation is to determine the cause(s) and contributing factors of an incident so that corrective/preventative actions can be developed and implemented to manage the risk and reduce the likelihood of recurrence. This will assist in identifying any latent issues that may affect the performance of the University’s Safety Management System (SMS).

Appointment of an investigation team

(16) The Senior Manager Work Health and Safety or their delegate shall ensure an investigation is undertaken in accordance with this procedure and the investigation team is appropriately resourced.

(17) The Senior Manager Work Health and Safety shall assign an adequately qualified and experienced Lead Investigator to facilitate an investigation into the incident to determine the cause/s and contributing factors so corrective/preventative actions can be developed and implemented.

(18) For all incidents requiring an ICAM investigation the Lead Investigator shall:

  1. have completed ICAM Lead Investigators Training Course;
  2. complete the required comprehensive investigation report, in association with the Investigation Team, including the forwarding of a Corrective Action Plan report containing the Investigation Team’s recommendations to the respective work area Senior Management;
  3. liaise with the work area during the investigation process;
  4. undertake the investigation process in accordance with the provisions of the ICAM methodology; and
  5. distribute the investigation report.

(19) Where contractors are involved in an incident, including high potential incidents, they are to provide access to people, sites and other resources as needed to fully investigate the incident and implement corrective and preventative actions to prevent recurrence.

Investigation response timeframes

(20) With the exception of a preliminary report, where an investigation cannot be completed within 30 days a reason must be reported and extension approved by the Director People and Culture.

Table 3: Investigation Response Timeframes

Actual or Potential Consequence Deliverable Timeframe
Extreme / Major / Notifiable Preliminary Report 5 working days
Incident Investigation Report complete (ICAM) 30 working days 
Moderate Accident, Incident and Injury Report, Section C – PEEPO Investigation 30 working days 
Minor Insignificant Accident, Incident and Injury Report, Section B Form (or Section C – PEEPO Investigation as required) and Work, Health and Safety advice. 30 working days 
In Table 3, PEEPO refers to People, Environment, Equipment, Procedures, Organisation.

Relationship to other investigations

(21) Any one incident may attract several different investigations, performed by external agencies or authorities. Such authorities may include Emergency Services, EPA or WHS Regulator (none of whom are bound by this reference). Investigators may be called upon to coordinate their activities with those conducting these investigations.

(22) Investigations that may also arise include:

  1. Coronial investigation: a possible legal requirement in the incident of a fatality, or other serious outcome of an incident or discovery of potential human remains. This will seek primarily to establish cause of death or other outcome and may involve the handing down of recommendations aimed at avoiding a recurrence of the circumstances or another outcome. The findings may also contain direct indications of fault, blame or regulatory authority response.
  2. Police inquiry: the police may undertake an inquiry to determine whether an unlawful act has played a part in events leading to an incident. Such an inquiry may result in persons being charged with an offence if an unlawful act is detected.
  3. Regulatory authority inquiries: regulatory authorities may conduct inquiries where there is suspected non-compliance with provision of legislation.

Corrective and preventative actions

(23) Where system deficiencies have been identified through the investigation process, recommendations for corrective actions shall be made. A Corrective Action Plan should be developed in alignment with the event investigation recommendations to improve existing systems, implement new systems of work, and to minimise recurrence and reduce risk. It is important that corrective actions have beneficial impact.

(24) Corrective actions recommendations may be a result of:

  1. a gap analysis;
  2. contributing factors identified in the absent and failed defences; and/or
  3. organisational factors arising out of the ICAM analysis.

(25) Notwithstanding any immediate mitigation actions, the responsible work area is required to develop a Corrective Action Implementation Plan based on recommendations from the investigation outcomes. The development and implementation of the Corrective Action Plan occurs when the incident investigation report has been agreed to and signed by the work area representative. The Lead Investigator may facilitate the development of the Corrective Action Plan with the work area representative.

(26) In summary, the respective work area is accountable for:

  1. developing an appropriate and effective Corrective Action Plan which addresses the incident Investigation recommendations.
  2. reviewing previous actions from similar events to ensure effectiveness in corrective actions being developed.
  3. liaising with all action assignees prior to the action being assigned.
  4. monitoring the due date for completion of the agreed corrective actions.
  5. action completion notification to Work, Health and Safety.

(27) Following completion of all actions, closure of the incident is recorded by Work, Health and Safety. The Work, Health and Safety post event review process assesses compliance to the above requirements and will determine action plan effectiveness.

Hierarchy of control

(28) As part of post incident corrective action management strategy, Work, Health and Safety and work area representatives need to stipulate control measure(s) to be put in place. The hierarchy of controls framework is utilised to determine appropriate control measure(s) and are selected from the highest order commencing with implementing controls to eliminate the hazard. For further information on the hierarchy of control framework see Hazard Identification Risk Assessment and Control Procedure.

Completion Timeframes and communicating outcomes

Table 4: Corrective action planning, completion timeframes and communicating outcomes

Class Deliverable Accountable
Extreme
Major
Notifiable
Corrective Action Plan to be developed within three working days from the completion of the incident investigation report. Corrective actions to be completed within 30 working days. Evidence of action close out shall be submitted to WHS Team, e.g. photographic evidence, updated Safe Work Procedure written or reviewed, etc. Lessons Learnt - An Initial Lessons Learnt should be released within 7 days of the event by Work, Health and Safety. WHS Bulletin – A final Safety Bulletin should be released within 14 working days from the completed investigation. Work area delegate with Work, Health and Safety
 
Moderate Corrective Action Plan to be developed within three working days from the completion of the event investigation report. Corrective actions to be completed within 30 working days. Evidence of action close out are to be should be submitted to Work, Health and Safety for review. Closure of incident by email notification. Lessons Learnt – An initial Lessons Learnt should be released within 7 working days of the event. Work area delegate
Work, Health and Safety
Minor
Insignificant
Corrective Action Plan to be developed with details passed onto Work, Health and Safety within 4 working days from the completion of the event report. Closure of incident by email notification. Work area delegate
Work, Health and Safety

Notifiable incidents

(29) The Work Health and Safety (National Uniform Legislation) Act 2011 Part 3 requires the WHS Regulator to be notified of certain incidents. The following incidents are notifiable:

  1. the death of a person; or
  2. a serious injury or illness of a person; or
  3. a dangerous incident.

Serious injury or illness

(30) As defined by the Work Health and Safety (National Uniform Legislation) Act 2011, a serious injury or illness of a person means an injury or illness requiring the person to have:

  1. immediate treatment as an in-patient in a hospital; or
  2. immediate treatment for:
    1. the amputation of any part of the body; or
    2. a serious head injury; or
    3. a serious eye injury; or
    4. a serious burn; or
    5. the separation of skin from an underlying tissue (such as degloving or scalping); or
    6. a spinal injury; or
    7. the loss of a bodily function; or
    8. serious lacerations; or
  3. medical treatment within 48 hours of exposure to a substance; and includes any other injury or illness prescribed by the Regulations, but does not include an illness or injury of a prescribed kind.

Dangerous incident

(31) A dangerous incident means an incident in relation to a workplace that exposes a worker or any other person to a serious risk to the person's health or safety emanating from an immediate or imminent exposure to:

  1. an uncontrolled escape, spillage or leakage of a substance; or
  2. an uncontrolled implosion, explosion or fire; or
  3. an uncontrolled escape of gas or steam; or
  4. an uncontrolled escape of a pressurised substance; or
  5. electric shock; or
  6. the fall or release from a height of any plant, substance or thing; or
  7. the collapse, overturning, failure or malfunction of, or damage to, any plant that is required to be authorised for use in accordance with the Regulations; or
  8. the collapse or partial collapse of a structure; or
  9. the collapse or failure of an excavation or of any shoring supporting an excavation; or
  10. the inrush of water, mud or gas in workings, in an underground excavation or tunnel; or
  11. the interruption of the main system of ventilation in an underground excavation or tunnel; or
  12. any other event prescribed by the Regulations; but does not include an incident of a prescribed kind.

(32) A notifiable incident must be reported immediately to Work, Health and Safety, the Director People and Culture, and the immediate supervisor as soon as reasonably practicable with 24 hours. Failing to report a ‘notifiable incident’ is an offence and penalties apply.

Preservation and initial collection of evidence

(33) Subject to external authority involvement, as soon as practicable after the scene is made safe and is under University control, the immediate work area or Senior Manager Work Health and Safety shall appoint a person to secure the incident scene and preserve any evidence in accordance with REACT Protocol (Appendix 1).

  1. This includes any plant, chemical, substance, structure or thing associated with the notifiable incident until an inspector arrives at the scene or any earlier time that an inspector directs. 

(34) All incidents that are notifiable to a regulator (EPA, Worksafe – NT, NSW, VIC and WorkCover - Qld and SA, etc.) will also be reportable to University Council and the Vice-Chancellor's Advisory Committee.

Roles and Responsibilities

Vice-Chancellor, Pro-Vice Chancellors, Directors, Deputy CEOs and Managers

(35) The Vice-Chancellor, Pro-Vice Chancellors, Directors, Deputy CEOs and Managers are responsible for ensuring:

  1. appropriate resources and processes are implemented for reporting, recording, classification, investigation and the management of work health and safety incidents; and
  2. all work health and safety incidents are managed effectively, and reporting requirements are met.

Work Area Manager

(36) The Work Area Manager is responsible for ensuring: 

  1. workers under their supervision are made aware of this procedure;
  2. the responsible Manager, the investigation team, and the work area representative are responsible for ensuring the investigation report is accurate and complete; and
  3. that a subject matter expert or safety specialist is provided to the representative of the investigation team, if technical or quality support is required.

Senior Manager Work Health and Safety 

(37) The Senior Manager Work Health and Safety is responsible for ensuring:

  1. notifiable, extreme and major incident investigation reports contain all relevant information (with reference to the ICAM methodology) to enable the University Senior Legal Officer to provide legal advice based on accurate and complete information;
  2. providing an incident briefing, as required, to the Vice-Chancellor, Vice-Chancellor's Advisory Committee, and/or the University Council so their legal accountabilities may be determined (refer to Table 2: Incident Notification Responsibilities); and
  3. all external authorities including the WHS Regulator, or Emergency Services are contacted so they may attend an incident scene.

First responder

(38) First responder(s) are responsible for:

  1. ensuring the injured person is attended to;
  2. considering the welfare of witnesses and others;
  3. ensuring the incident area to ensure it is safe (preserving the incident site if a significant incident/event);
  4. implementing any corrective actions necessary to prevent an injury/reoccurrence; and
  5. ensuring that incidents/hazards are reported in to the HSE Team within 24 hours of the occurrence/identification.

University contractors and representatives

(39) University contractors are responsible for reporting all work health and safety incidents to their supervisor as soon as reasonably practicable within 24 hours.

(40) Where a contractor is involved in an incident, the University representative is responsible for reporting in accordance with the notification classification requirements.

Workers and other individuals

(41) Workers and other individuals are responsible for: 

  1. taking reasonable care of their own health and safety;
  2. taking reasonable care that their acts or omissions do not adversely affect the health and safety of other persons;
  3. reporting all work health and safety incidents to their supervisor as soon as reasonably practicable within 24 hours; and
  4. assisting relevant teams in the investigation process.
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Section 5 - Relevant Definitions

(42) In the context of this document:

  1. Accident/Incident means an unplanned event or uncontrolled hazard resulting in, or having the potential for injury, ill-health, damage or other loss.
  2. Incident Cause Analysis Method (ICAM) means a systematic incident investigation analysis method that enables identification of systemic health, safety, security or environmental deficiencies, assists investigation teams to identify incident root and causal factors and ensures recommendations are focused on what needs to be done to reduce recurrence.
  3. Near Miss means any unplanned incidents that occurred at the workplace which, although not resulting in any injury, disease, plant and equipment or environmental damage but had the potential to do so.
  4. Notifiable Event means any event that is to be reported to NT Worksafe as outlined in Sections 35-37 of the Work Health and Safety (National Uniform Legislation) Act 2011
  5. Worker, as defined by the Work Health and Safety (National Uniform Legislation) Act 2011 as any person who carries out work in any capacity for the University, including but not limited to:
    1. University staff members;
    2. Contractors;
    3. Subcontractors and their employees;
    4. Apprentices or trainees;
    5. Students gaining work experience, and volunteers; or
    6. Employees of a labour hire company assigned for work at the University.
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Section 6 - Non-Compliance

(43) Non-compliance with Governance Documents is considered a breach of the Code of Conduct – Staff or the Code of Conduct – Students, as applicable, and is treated seriously by the University. Reports of concerns about non-compliance will be managed in accordance with the applicable disciplinary procedures outlined in the Charles Darwin University and Union Enterprise Agreement 2022 and the Code of Conduct – Students.

(44) Complaints may be raised in accordance with the Code of Conduct – Staff and Code of Conduct - Students.

(45) All staff members have an individual responsibility to raise any suspicion, allegation or report of fraud or corruption in accordance with the Fraud and Corruption Control Policy and Whistleblower Reporting (Improper Conduct) Procedure.