DRAGON BOATING WA
Hazard/Incident Notification
and Investigation Form
This form is for the notification and investigation of hazards, near misses and injuries to enable the
risk to be identified and minimised. It is also used as a register of injuries.
This form requires completion within 24 hours of an incident occuring. All relevant parts of the
form must be completed.
Notification
Part A1, A2, A3:
To completed by witness or injured person. If help is required, ask your
sweep or coach.
Part B:
To be completed by sweep involving in the incident.
Investigation
Part C:
Part’s D and E:
PART A.1
To be completed by President in consultation with sweep/coach.
To be completed by Club President
HAZARD/NEAR MISS/INJURY DETAILS (To be completed by Observer or injured person)
INCIDENT:
Please tick:
□
□
HAZARD
HAZARD = SOURCE OF POTENTIAL HARM TO
PEOPLE, EQUIPMENT OR THE ENVIRONMENT
□
NEAR MISS
NEAR MISS = EVENT OCCURRED WHICH DID NOT
RESULT IN AN INJURY
INJURY
INJURY = EVENT OCCURRED WHICH RESULTED
IN AN INJURY
NAME (Reported By)
CONTACT NUMBER
POSITION
DATE OF EVENT
/
/
TIME OF EVENT
:
AM/PM
CLUB: SWEEP
DATE OF BIRTH (Optional)
/
/
MALE
FEMALE
CONTACT NUMBER
WITNESSES (If any)
LOCATION (Including address)
In what activity was the individual(s) participating at the time of the incident (e.g. training, regatta, corporate
event, etc):
WEATHER CONDITIONS AND PHYSICAL ENVIRONMENT
□
□
□ Over Cast
Fine
Rain
Night
HAZARD/NEAR MISS/INJURY DESCRIPTION:
□
□ Low Light □
Cold
□
Storm □
Hot
Humid
Windy
□
□
Does a safe operating procedure exist for this task? Yes No
If yes, was it followed? Yes No
DETAILS OF DAMAGE SUSTAINED (Include any damage to equipment as result of incident)
IMMEDIATE ACTION TAKEN (What actions were immediately implemented to eliminate or minimise further impact or occurrence?)
PART A.2 INJURY NOTIFICATION DETAILS (To be completed by First Aider / Injured Person)
If no injury sustained, strike out part B with a diagonal line and go to part C.
NAME OF FIRST AID ATTENDANT (print)
PERSONAL PROTECTION EQUIPMENT (PPE) WORN AT TIME OF INJURY
□ Paddling Shoes □ Paddling Clothing □
TREATMENT
□ HOSPITAL
□ DOCTOR
Life Jacket
Hat
□
Glasses
Sun Screen
□ FIRST AID
(including emergency room)
If sent to doctor/hospital by –
□
□
□ NO TREATMENT
(Including self administered)
□ Private vehicle □
Company vehicle
□ Taxi □
Ambulance
□
Public Transport
Please tick all applicable boxes-
INJURY TYPE
□ Abrasion
□ Amputation
□ Fracture
□ Hernia
BODY PART
CAUSE/AGENCY
Circle injured location/s at each side
FRONT VIEW
Right
Left
BACK VIEW
Left
Right
□ Animal
□ Biological
□ Needle Stick
□ Noise
Exposure
□ Bite/Sting
□ Bruising
□ Infection
□ Internal Injury
□ Confined space □ Plant/Equip.
□ Dust
□ Physical
assault
□ Burn
□ Concussion
□ Crush
□ Deafness
□ Dermatitis
□ Dislocation
□ Irritation
□ Laceration/cut
□ Multiple Injuries
□ Poisoning
□ Sprain
□ Strain
□ Electricity
□ Ergonomics
□ Fall from height
□ Haz. Substance
□ Heat/cold
□ Hit by Object
□ PPE
□ Repetition
□ Slide/Cave in
□ Slip/Trip/Fall
□ Striking object
□ Vehicle
accident
□ Foreign Body
□ Other (specify)
□ Stress/anxiety
□ Job Design
□ Lighting
□ Man. Handling
□ Other (specify)
□ Ventilation
□ Verbal assault
□ Vibration
FIRST AIDER’S COMMENTS:
FIRST AIDER’S SIGNATURE:
DATE:
INJURED PERSON’S SIGNATURE:
DATE:
IS THIS A RECURRENCE OF A PREVIOUS INJURY?
YES
NO
DESCRIPTION OF PREVIOUS INJURY:
PART A.3
SIGN OFF
COMPLETED BY: (Person completing this notification form)
SIGNATURE:
DATE:
PART B
DRAWING OF INCIDENT
A
-
OUR CLUB BOAT
B
-
OTHER BOAT
A
B
PART C INVESTIGATION
The purpose of this investigation is to identify the cause and actions that need to be taken to prevent
reoccurrence of the hazard/incident and not to lay blame.
Describe how the incident occurred including the cause and circumstances:
Are you aware of a similar incident occurring before?
No
Yes
If ‘YES’, please elaborate:
Describe what was happening when the event occured:
WHAT CONDITIONS CONTRIBUTED TO THE INCIDENT?
□
Equipment malfunction
Pre-existing Injury
□
□
Pre-existing Condition
Equipment design
□
Environment
□
Other (describe): ______________________________________________________________________________________
WHAT ACTS CONTRIBUTED TO THE INCIDENT?
□
Hazard(s) not identified
PPE not used
Hazard(s) not controlled
□
□
PPE incorrectly used
□
Procedures not followed
□
□
Incorrect equipment
Other (describe): ______________________________________________________________________________________
WHAT ADMINISTRATIVE / SYSTEM FAILURES CONTRIBUTED TO THE INCIDENT?
□ Inspections □
□ Maintenance □
Hazard ID & Risk Control
Training & Procedures
Supervision
□
Communications
□
Emergency Systems
□
Other (describe): ______________________________________________________________________________________
RISK CALCULATOR – Calculate the risk score for the identified hazard/incident
CONSEQUENCES
LIKELIHOOD
A
(Almost Certain)
Is expected to occur at most times
B
(Likely)
Will probably occur at most times
C
(Moderate)
Might occur at some time
D
(Unlikely)
Could occur at some time
E
(Rare)
May occur in rare circumstances
RISK
RATING
Insignificant
Minor
Moderate
Major
Catastrophic
First Aid Injury
0-low $ loss
Medical treatment
Low-medium $ loss
Hospital Treatment
Notification to WHSQ
Medium – high $ loss
Single Fatality
Serious bodily injury
Major $ loss
Multiple fatalities
Large $ loss
M - 52
M - 44
H - 64
H - 56
E - 76
H - 68
E - 88
E - 80
E - 100
E - 92
L - 36
M - 48
H - 60
E - 72
E - 84
L - 28
L - 20
L - 40
L - 32
M - 52
M - 44
H - 64
H - 56
E - 76
H - 68
ACTION REQUIRED
E
Extreme Risk
Immediate action required
H
High Risk
Senior Management attention needed
M
Moderate Risk
Management responsibility must be specified
L
Low Risk
Manage by routine procedures
Enter your risk
rating here
CORRECTIVE ACTIONS
Are further controls required to prevent a re-occurrence? YES
NO
If YES, provide an overview of the corrective actions to be taken:
If NO, briefly state reason for no further actions:
INVESTIGATION TEAM SIGNATURES
Club board member
signature:
Name:
Date:
Club President signature:
Name:
Date:
Include names, signatures and dates for other people involved in the investigation:
Name:
Signature:
Date:
Name:
Signature:
Date:
Name:
Signature:
Date:
Name:
Signature:
Date:
PART D
ACTIONS TO BE UNDERTAKEN OR IMPLEMENTED
RESPONSIBLE PERSON
Club President’s Signature:
Name:
PART E
NOTIFIED
DUE DATE
Date:
SIGN OFF
Have all required corrective actions been completed? YES NO N/A
If ‘NO’, then have all required corrective actions been assigned and due dates set for completion? YES NO
If ‘NO’, provide explanation why corrective actions have not been assigned and/or due dates set:
CLUB PRESIDENT’S NAME:
Comments:
SIGNATURE:
DATE:
DBWA USE ONLY
NAME:
SIGNATURE:
Date received:
Date entered:
PROCESS: The aim of an incident investigation is to determine the root cause of an incident and put measures in place
to mitigate the chances of such an incident reoccurring. A useful tool to determine the root cause is to keep asking
‘why?’ until no further answers are forthcoming. For example, if a piece of equipment malfunctioned, the question
‘why?’ prompts further consideration, such as whether or not the equipment was fit for purpose, properly maintained,
or if procedures and training were in place for its use.
All required corrective actions must be completed prior to closing out the incident. If the actions have not been
completed, they must be registered in the committee minutes for follow Up, along with deadlines for completion.
The DBWA needs to assess whether the corrective measures identified are sufficient to eliminate or control the hazard
(minimise risk), and whether the measures have been successfully implemented.
The investigation must not be closed out until all necessary corrective measures have been implemented and the risk
has been eliminated or minimised as far as practicable.
DBWA Board Comments:
NOTIFIED THE PERSON WHO REPORTED THE HAZARD/INCIDENT OF THE ACTIONS TAKEN
□
Name:
By email
□
By post
Signature:
□
Verbally
Date:
HAZARD/NEAR MISS/INJURY CLOSE-OUT
To the best of my knowledge and understanding, all required corrective actions been completed and the hazard or
risk has been sufficiently eliminated (where possible), or controlled or minimised as far as practicable.
Name and
position:
Signature:
Date: