View Current

WHS Incident and Investigation Procedure

This is the current version of this document. You can provide feedback on this policy to the document author - refer to the Status and Details on the document's navigation bar.

Section 1 - Introduction

(1) This procedure provides a framework for University Staff in the management of work health and safety incidents and their subsequent investigation.

(2) 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).

Top of Page

Section 2 - Compliance

(3) This is a compliance requirement of Part 3 ‘Incident notification’ of the NT Work Health and Safety (National Uniform Legislation) Act, and Regulation 699 (a), (b) of the NT Work Health and Safety (National Uniform Legislation) Regulations. This procedure is compliant with the incident notification obligations of NTWorkSafe.

  1. Work Health and Safety Policy
  2. Work Health and Safety (National Uniform Legislation) Act 2011
  3. Work Health and Safety (National Uniform Legislation) Regulations 2011
  4. Occupational Health and Safety Act 2004 (Vic)
  5. Occupational Safety and Health Act 1984 (WA)
  6. Work Health and Safety Act 2011 (NSW)
  7. Work Health and Safety Act 2011 (Qld)
  8. Work Health and Safety Act 2012 (SA)
  9. Hazard and Risk Management Procedure
  10. Code of Practice - How to Manage Work Health and Safety Risks
  11. Education Services for Overseas Students Act 2000
  12. Higher Education Standards Framework (Threshold Standards) 2021 (HSEF)
  13. AS/NZS 1885 Measurement of Occupational Health and Safety Performance
Top of Page

Section 3 - Intent

(4) This procedure provides the framework for incident notification, reporting, classification and investigation for all University campus’ and facilities. 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.

Top of Page

Section 4 - Relevant Definitions

(5) In the context of this document:

  1. Accident, Incident and Injury Report (AIIR) means the form that is used by University Staff to record and report all WHS accidents and incidents.
  2. Alternate Duties Injury means any work injury that results in work being assigned after the day of the incident occurrence that does not include all the normal duties of the person’s regular job.
  3. Behavioural Incident Report (BIIR) means the form can be used to report any of the following behaviours that are inappropriate, concerning or threatening, including:
    1. angry, aggressive communications (verbal or written);
    2. unwanted attention;
    3. written material (assignments, exams, emails or letters) that suggest a person may be unstable or have mental health issues;
    4. a statement about self-harm or suicide;
    5. sexual harassment (unwelcome sexual conduct of any kind);
    6. a notable change in a person’s behaviour that is cause for concern;
    7. stalking (repeated attempts to impose unwanted communication or contact);
    8. an uttered threat to harm another or damage property;
    9. pornography use that contravenes the University IT Policy and/or affects others;
    10. bullying (repeated, unreasonable conduct in the workplace);
    11. any act of physical violence, property damage, or production of a weapon; or
    12. violent critical incident on campus.
  4. Dangerous Incident means any incident in a workplace that exposes a worker or any other person to serious risk from immediate or imminent exposure to uncontrolled escape, spillage, leakage of a substance, uncontrolled implosion/explosion, fire, escape of gas/steam or pressurised substance or electric shock.
  5. Event/Incident means an unplanned incident or uncontrolled hazard resulting in, or having the potential for injury, ill-health, damage or other loss.
  6. First Aid Injury (FAI) means injuries treated by either a qualified First Aid officer, self or in some instances Medical Practitioner (not meeting the criteria of a MTI).
  7. 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.
  8. Job Safety Analysis (JSA) means a document prepared on-site in real time by a competent person in consultation with workers. The document guides the worker to identify hazards associated with the work that is to be performed and put in place controls to eliminate (or minimise) those hazards.
  9. Lost Time Injury (LTI) means occurrences that resulted in a fatality, permanent disability or time lost from work of one day/shift or more. An injury that requires corrective surgery is only included in the statistics if it occurs in the reporting year. LTI’s are recorded at the date of the incident, not at the time the surgery or acceptance of claim.
  10. Medical Treatment Injury (MTI) means an injury sustained by a worker at work that requires treatment to be administered by a medical practitioner and does not result in absence from work of at least one full working day or shift.
  11. 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.
  12. Notifiable Event means any event that is to be reported to NT Worksafe as outlined in Sections 35-37 of the WHS (National Uniform Legislation) Act. Motor Vehicle accidents or any other events that may require a Police Reports to be submitted e.g. fatality.
  13. Safe Work Procedure (SWP) means a document prepared by an independent person in consultation with workers (in most instances off site) prior to work being undertaken and stating the safe work method applied to the site and works. It is included in a ‘job pack’ and forms part of the instructions for performing the work and should be reviewed by the work supervisor prior to work being undertaken.
  14. SEW Manager means Safety, Emergency and Wellbeing Manager.
  15. SEW Team means Safety, Emergency and Wellbeing Team.
  16. Worker means any person who carries out work in any capacity for the University, including but not limited to:
    1. University’s 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.
Top of Page

Section 5 - Procedures

Incident Response

(6) The University shall use the systematic Incident Cause Analysis Method (ICAM) as set out in Table 1. Immediately following an incident, the most senior onsite employee, or emergency response personnel shall organise and arrange for the implementation of any measures required to:

  1. make incident site safe;
  2. initiate emergency response (as required);
  3. prevent escalation and preserve incident site; and
  4. record incident details.

Hierarchy of Authority at an Incident Scene

(7) External authorities including NT WorkSafe, Coroner, Police Officers or other Emergency Services may attend an incident site; and a representative from an external authority through invested legislative powers may take control of an incident site.

(8) In these situations, the University’s prime responsibility is to maintain site safety, reduce further risk to people, heritage and/or environment, provide any specialist advice and render assistance to the external authority. The external authorities may take possession of physical evidence from the scene. Advice, evidence or assistance provided to external authorities should be done in consultation with a Senior University representative from the immediate workplace and detailed notes taken of all transactions.

Preservation and Initial Collection of Evidence

(9) 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 SEW Manager shall appoint a person to secure the incident scene and preserve any evidence. The appointed person shall:

(10) Prevent non-essential personnel access to the area. This may include restricting access with temporary barriers, posting warning signs or by placing people at strategic locations.

(11) Assess the risks associated with providing assistance and implement necessary control measures for the safe provision of help or to prevent situation escalation, further injury, damage, environmental and/or cultural heritage harm.

(12) Not move or interfere with equipment involved (unless it is necessary to make site safe) without permission or authority of a regulatory Inspector, Police/Emergency Services or the responsible Senior University representative or SEW Manager.

(13) For plant/asset related incidents where failed or damaged equipment is quarantined, the responsible Senior University representative or delegate’s approval should be sought prior to any removal from site and direction as to when and where these items are to be stored for further investigation/analysis by an external regulator or Investigations Team.

(14) Record any necessary site changes caused during the incident response stage, by taking photographs, making notes or drawings.

(15) Secure and preserve any equipment involved in the incident.

(16) Mark any evidence collected as ‘Privileged and Confidential’.

Incident Classification and Investigation

(17) The level of investigation classification will be determined by applying the guidance Table 1. As an example, an incident classified as Extreme or Major would require a formal ICAM investigation.

Table 1: 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 MTI;
First Aid treatment;
Minor short-term inconvenience;
Near Miss.
AIIR form
Note 1: Regardless of classification, all incidents must be reported to the delegated Senior University representative and SEW Team.
Note 2: All incidents that are notifiable to a regulator (EPA, NT WorkSafe etc.) will also be reportable to University Council and Executive Leadership Group.

Incident Notification

(18) Incident notification is required for the following reasons:

  1. Notification to external or legislative authorities within applicable timeframes (where required by legislation).
  2. Appropriate emergency response (where necessary).
  3. Inform appropriate levels of the University’s management and staff of incident basic details in a timely manner (refer Table 2).
  4. Preservation of evidence and the security of the incident scene.
  5. Where relevant, requests from the University Legal for the conduct of a confidential investigation for providing legal advice to University and its Officers and/or anticipated litigation.
  6. Identification of a risk or hazard that requires attention.
  7. It is imperative that all incidents are reported to the appropriate persons,
  8. Incidents are recorded by SEW team and classified.
  9. Required notifications are made to external authorities.
  10. Appropriate incident response is initiated as quickly as possible.

Notification of Catastrophic/Major/Moderate and Notifiable Incidents

(19) All workplace incidents are to be reported to the relevant supervisor/manager and an AIIR completed. If the incident is classified, or has the potential of becoming classified, as extreme, major or notifiable notification must occur as set out in Table 2 and 3.

(20) Guidance for incident notifications to relevant supervisor/manager to support the University’s compliance with adequate incident response and external authority notification is given in Table 2. Timely reporting of incidents to the relevant supervisor/manager is required in accordance with Table 2, followed reporting to SEW team.

Table 2: Internal / External Notification Timeframes

Incident Category
Refer Table 1
Internal Notification
in accordance with requirements set out in Table 3
External Regulatory Notification
Extreme
Major
Immediate, within 1 hour of incident Potential for Police, Fire, Coroner, EPA or WorkSafe involvement
NOTIFIABLE
Incident involved electrical equipment or electrical work?
Person sustained serious injury or illness?
Dangerous incident occurred?
Refer to Part 3: Incident Notification of the WHS (NUL) Act
Immediate, within 1 hour of incident Immediate verbal notification required; followed by
written notification within 24hrs of incident
(NT WorkSafe)
Moderate Within 24 hours of incident AIIR Process
Minor and Insignificant Within 48 hours of incident AIIR Process
POTENTIAL
Catastrophic, Major, NOTIFIABLE
As soon as reasonably practicable or within 24 hours of the incident AIIR Process

(21) All Extreme, Major or Moderate-risk incidents (refer to Table 1) or incidents having the potential to become so are to be reported as per Table 3 below, via telephone or text message.

Table 3: Incident Notification Responsibilities

  Person / Position Notifying Responsibility
Major n Extreme / Notifiable Person reporting the incident Work area senior manager
Work area Senior Manager Vice-Chancellor and Vice President Operations
SEW Manager
Emergency Response – University Secretary, as required
VC and/or PVC Operations University Council and Executive Leadership Group, University Legal Group
SEW Manager SEW Team
External: regulators, legal etc.
Council, ELG (via monthly reporting)
SME to advise on incident (as required)
Moderate / Potentials A High-risk incident or hazard / incident with potential of becoming a High-risk incident or greater (refer to Table 2) requires that the following persons be notified:
Responsible manager/supervisor
SEW Manager
Minor/Low All incidents to be reported to the relevant supervisor and SEW team as soon as reasonably practicable

Incidents Involving Contractors

(22) Contractors involved in an incident are to notify their nominated University representative by telephone as soon as possible. The University representative is then responsible for reporting the incident in accordance with the notification classification requirements.

Accountability and Escalation

(23) The work area where an incident occurred shall manage the incident through to completion with the support of SEW Team; SEW Manager is the final authority for the classification of an incident or hazard.

Recording of Incidents

(24) 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 the SEW Team 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.

(25) SEW Team is responsible for ensuring details are recorded of incidents involving Contractors undertaking work on behalf of the University:

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

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

(27) All incident information collected, including records of notifiable incidents, are to be recorded in accordance with the WHS Records Management 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.

Investigation

Appointment of Investigation Team

(28) The SEW Manager or their delegate shall ensure an investigation is undertaken in accordance with this procedure and the investigation team is appropriately resourced.

(29) The SEW Manager 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.

(30) 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. laise with the work area during the investigation process.
  4. undertake the investigation process in accordance with the provisions of the ICAM methodology.
  5. distribute the investigation report.

(31) 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.

SEW Manager

(32) SEW Manager shall ensure Notifiable, Very High and Extreme incident investigation reports contain all relevant information (with reference to the ICAM methodology) to enable the University Legal to provide legal advice based on accurate and complete information.

Management of Due Diligence

(33) SEW Manager to provide an incident briefing, as required, to Vice President Operations, Vice-Chancellor, Executive Leadership Group, and/or the University Council so their legal accountabilities may be determined (refer to Table 3: Incident Notification Responsibilities).

Responsibilities and Administration

(34) The responsible Senior Manager or delegate, the investigation team, and the work area representative are responsible for ensuring the investigation report is accurate and complete.

(35) If technical or quality support is required by the work area Manager or delegate, this should be provided by a representative of the investigation team, a subject matter expert or safety specialist.

Investigation Response Timeframes

Table 5: Investigation Response Timeframes

Class Deliverable Timeframe
Extreme Major or Notifiable Preliminary Report as required may be verbal if Senior Manager satisfied 5 working days
Incident Investigation Report complete (ICAM) 30 working days - *NOTE
Moderate Final Investigation Report 30 working days - *NOTE
Minor Insignificant Incidents classified as Medium or Low risk are to be managed in accordance with AIIR Notification Forms and SEW Team advice.
*NOTE If an investigation cannot be completed within 30 days a reason must reported and extension approved by VP Operations

Relationship to Other Investigations

(36) Any one incident may attract several different investigations, performed by external agencies or authorities. Such authorities may include Police, the Electrical Safety Office, or NT WorkSafe (none of whom are bound by this reference). Investigators may be called upon to coordinate their activities with those conducting these investigations. 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 enquiry 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

(37) 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.

(38) 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.

(39) 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 Correction 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.

(40) 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 the SEW Team.

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

Hierarchy of Control

(42) As part of post incident corrective action management strategy, SEW team 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, as follows:

  1. Elimination: Unless a hazard is removed, the risk associated can never be eliminated. For instance, a requirement to work on de-energised electrical equipment only removes the risk of electric shock. Elimination is the preferred solution and should be attempted in the first instance. If this is not possible, the risk must be minimised by measures considered in the following order.
  2. Substitution: Involves replacing the hazard by one that presents a lower risk.
  3. Isolation: Involves some structural change to the work environment or work process to place a barrier to, or interrupt the transmission path between, the worker and the hazard.
  4. Engineering: Involves some form of redesign to enable the task to be carried out in a different way.
  5. Administration: (soft control) These reduce or eliminate exposure to a hazard by adherence to procedures or instructions. Documentation should emphasise all the steps to be taken and the controls to be used in carrying out a task safely.
  6. Personal Protective Equipment: (soft control) Is worn by people as a barrier between themselves and the hazard. The success of this control is dependent on the protective personal equipment being chosen correctly, as well as fitted correctly and worn always when required.

Completion Timeframes and Communicating Outcomes

Table 6: 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 SEW Team, e.g. photographic evidence, updated SWP written or reviewed, JHA etc.
Safety Alert - An Initial Safety Alert should be released within 7 days of the event by SEW Team.
Safety Bulletin – A final Safety Bulletin should be released within 14 working days from the completed investigation.
Work area delegate with SEW Team
SEW Team
SEW Team
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 SEW Team for review.
Safety Alert – An initial Safety Alert should be released within 7 working days of the event.
Work area delegate
SEW Team
Minor
Insignificant
Corrective Action Plan to be developed with details passed onto SEW Team within 4 working days from the completion of the event report.
Safety Alert – SEW Manager to determine requirement
Work area delegate
SEW Team