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(1) The purpose of this procedure is to ensure reporting of Workplace Health and Safety (WHS) events at Southern Cross University (SCU) are appropriately managed and controlled. (2) The purpose of this procedure is to ensure Southern Cross University’s management, employees, contractors, students, visitors and others are aware of the standardised approach across the University so that workplace health and safety (WHS) events are correctly reported, investigated, classified, and actions assigned to manage and prevent future unplanned events from occurring. (3) All employees, students and others including both independent contractors and contractors under SCU control are to be made aware of and follow this procedure. (4) This Procedure applies to all SCU Work Units and sites. The procedure aligns with WHS legislation in the relevant jurisdictions SCU operates in. (5) This procedure aims to assist SCU employees through the steps associated with incident management for WHS events. The procedure provides details on: (6) This Procedure does not provide detail on: (7) An incident is defined as an unplanned event that did, or could result in: (8) Whenever an event transpires, immediate action should be taken to prevent or where not possible to prevent, control and minimise further impact where it is safe to do so. Where it is not safe to take action to control or correct the event, emergency services should be contacted to render assistance as per WHSMP05: First Aid, Emergency Preparedness and Response Procedure. The initial response should consider the following elements: (9) The University shall provide adequate support to assist person(s) who have been affected by an incident. This may include: (10) Incidents and non-conformances must be classified using the Event Classification Matrix (see Table 1 below). Incidents shall be assigned one or more classifications depending on the outcomes of the event. These impacts may include safety, health and wellbeing. All incidents will be assigned: (11) Classification of event outcomes matrix (Appendix 1) outlines the base determination on what constitutes a First Aid Injury (FAI), Medical Treatment Injury (MTI), Lost Time Injuries (LTIs), and permanent alteration to an individual’s future. Where uncertainty exists around the correct incident classification to use, you should seek advice from SCU WHS or the Work Unit Manager. (12) All investigations will be undertaken based on the MRO or Potential consequence level in line with the requirements set out in this document. Where more than one event category is identified during the incident classification, the level of investigation will be determined by the highest severity level. (13) All events, including near misses, shall be recorded to allow effective management, investigation, and communication of implemented actions. Lessons learnt will also be recorded to assist in the prevention of similar events occurring in the future. Internal reporting of incidents and escalation shall be completed following Table 2, unless the incident is deemed to warrant a more urgent notification or wider distribution than indicated. Where an injury or illness triggers the injury management and/or workers compensation process, the process outlined in the Injury Management Procedure shall be followed to ensure correct reporting and engagement of relevant parties. (14) Reporting Supervisors must inform the WHS Manager of a potential SIRS 1&2 event immediately. Once received the WHS Manager needs to inform the Vice Chancellor and other relevant stakeholders as per Table 2. Applicable timeframes are within 1 hour for SIRS1 incidents and 4 hours for SIRS2 events. SIRS 1&2 WHS Alert (WHSMP17-FOR-05) is to be completed and submitted through the WHS Partner to the Vice Chancellor, University Council (SIRS1 only), Head of Work Unit and WHS Manager within the day for review and dissemination to the wider business where applicable. (15) Exact details and information reported shall be concise, and factual, and only provide a summary of the event. The Manager with the support of the WHS Partner are to ensure the injured employee is provided with the appropriate medical care and early return to work intervention in line with the Injury Management Procedure. The following information is to be conveyed as part of the initial notification for SIR1&2 events via phone call: (16) For SIRS 1 incidents, the Vice Chancellor shall seek advice from SCU Legal on whether to establish legal professional privilege of the event and subsequent advice. If the incident is considered a crisis, then the Vice Chancellor will determine if the Critical Incident Team (CIT) needs to be activated. The process to be followed is outlined in detail in the SCU Emergency Management Plan. (17) The SCU internal reporting requirements do not remove the responsibility for other reporting requirements, such as to regulatory authorities under statutory or regulatory requirements. SCU report all notifiable incidents arising from the conduct of the business to the relevant authorities as required under relevant acts and regulations. (18) Where it is a requirement to notify the Regulator, the Head of Work Unit shall discuss the event with the WHS Manager in consultation with SCU Legal as to whether the incident should be treated as Legal Privilege. Where it is determined that Legal Professional Privilege will be applied WHS shall report to the relevant regulator. When reporting events to the regulator details shall be factual and concise, providing only a summary of what is known. (19) A record of the notification and subsequent correspondence with the regulator should be documented and logged in RiskWare as part of the incident recording. Failure to notify authorities of a notifiable incident may lead to significant fines for each offence. WHS shall predetermine applicable areas of jurisdiction and identify reporting Regulators and Authorities so that in the unfortunate event of a notifiable incident the correct reporting can be undertaken within set timeframes. The definition of a notifiable incident and its associated reporting requirements vary across jurisdictions and should be known by WHS to ensure accurate reporting. WHSMP03: WHS Legal and Other Requirements Procedure refers to the relevant state regulatory authority and reporting requirements. (20) The site of the notifiable incident shall be preserved and not be disturbed without the approval of the regulatory authority. Exemptions to the above include the need to: (21) Release of scene correspondence from the regulator shall be documented and evidence uploaded to RiskWare as part of the investigation. (22) All events are to be reported in RiskWare within 24 hours of transpiring. (23) Where there is no access to RiskWare, Section 1 of WHSMP17 – FOR – 04 - Basic Investigation Form is to be completed following the initial notifications following Table 1 to document all relevant information about the event. A copy of the completed and signed form is to be uploaded to RiskWare when access is available. (24) The sole objective of the investigation of an incident or non-conformance shall be operational learning, the prevention of future incidents and corrective actions of systemic contributory factors or non-conformances. It is not the purpose of this activity to apportion blame or liability. The level of investigation required is determined by the classification of the event. The event classification is based on the maximum severity level of the actual and maximum reasonable outcome (potential) severity of the event. The below table, Table 3 outlines the level of investigation and required outputs for each event classification. (25) All SIRS 1-2 classified events are to undergo detailed investigations using the incident cause method analysis (ICAM) and documented in the ICAM investigation template (WHSMP17-FOR-01). SIRS 3, 4, and near-miss events shall be required to have basic investigations undertaken using RiskWare. All incidents must be investigated within nominated timeframes as per below Table 3. (26) On receipt of advice of an incident, SCU must immediately investigate the circumstances of the event and determine follow-up action to be taken. This shall include immediate actions, such as: (27) The Investigation Owner is the most senior role with accountability for the work where the incident occurred. This role is designated as per the table below. The appointment of the Lead Investigator shall also be undertaken in accordance with the details in Table 4 by the Investigation Owner. (28) Lead investigators must meet the below competency levels per the SIRS classification of the Incident. Investigations may also be undertaken by a specialist third party or regulator where deemed necessary. Approval will be gained from the WHS Manager or equivalent Council member before engaging any external party/regulator in an investigation. (29) The investigation team shall: (30) The collection of evidence enables the incident to be fully described and the causes to be determined. Key considerations to be determined when collecting evidence include the who, what, when, where, why and how. Examples of key methods for evidence collection include direct observations, document review, and interview/witness statements as outlined in the sub-sections below. (31) Incident scenes shall remain undisturbed pending the collection of evidence for investigation purposes. If movement of evidence becomes necessary to make people or the scene safe, the location and situation of items to be moved shall be made to allow memory recall as accurately as possible. When collecting the data investigators should identify all conditions, actions, or deficiencies that may have contributed to the event using the five known categories from the incident cause analysis method (ICAM) data collection: people, environment, equipment, procedures, and organisation. (32) All evidence collected as part of the investigation should be uploaded into RiskWare as part of the record-keeping process. (33) This is pertinent to the understanding of the circumstances and the events leading to the incident. A variety of information sources will be used to collect the necessary data for the reconstruction of the event. To ensure the continued availability of such data for safety improvement, information sources need to be protected. (34) Although the investigation should primarily focus on the factors that are most likely to have influenced action, the dividing line between relevance and irrelevance is often blurred. Data that initially may seem to be unrelated could later prove to be relevant once the relationship between the different elements of an occurrence is better understood. (35) Direct observations can take the form of: (36) Documentation spanning a broad spectrum of the operation can assist in establishing what has transpired coupled with providing evidence of prior risk assessments, inspections, and training records. For example: (37) Interviews conducted with individuals directly or indirectly involved in the incident can provide a principal source of information for any investigation. In the absence of measurable data, interviews may be the only source of information. More importantly, interviews are often the only way to answer the important ‘how’ question, which in turn will facilitate the establishment of appropriate and effective safety improvement recommendations. (38) Witness statements can also provide an opportunity to check back on any issues arising from the examination of the physical and documented evidence. Interviews should not only include those who were directly involved in the event but also witnesses, line managers, and subject matter experts. They must realise personal limitations as investigators cannot be experts in every field related to the operational environment. When necessary, they must be willing to consult with other professionals during an investigation. (39) When collecting witness statements, they must be documented in the persons' own words, using WHSMP17-FOR-03 Witness Record Form or document containing the same elements to ensure a factual account of events is recorded. All witness statements collected are to be uploaded into the RiskWare for future review where required. Witness statement should be collected for all incidents where possible. (40) Once the data has been collected it is important that it is organised into a logical and sequential order to build up a picture of the incident and its causes. This is often an interactive process, between evidence gathering and the development of causes, which should include the creation of an event timeline, cross-linked to the various pieces of evidence. (41) The lead investigator should also: (42) The analysis shall provide systematic reasoning about how the incident happened and enable the drawing of conclusions and identification of actions to eliminate or mitigate the risk. (43) The output of the data analysis phase should be a set of events that agrees with recorded information, and which unifies the views of the various persons who were involved in these events immediately before and after the occurrence. (44) Any drawing of conclusions shall be based on collected and analysed information, generally presented by the following categories: (45) Identifying the lessons to be learned from a safety occurrence requires an understanding of not just what happened, but how and why it happened. Therefore, the investigation should look beyond the obvious causes and aim to identify all the contributory factors, some of which may be related to weaknesses in the system’s defences or other organisational issues. (46) All incident investigations undertaken for SCU events should follow the standard SCU methodology (in RiskWare and outlined in this document). As outlined earlier in Table 3, the level of detail and documents required to be undertaken will vary based on the severity and risk to the University. (47) SIRS 1 and 2 events are to be recorded using the WHSMP17-FOR-01 - ICAM Investigation Template or RiskWare investigation tool. Lower severity events (SIR 3/4) investigations will be documented using the WHSMP17-FOR-04 - Basic Investigation Template or RiskWare investigation tool. (48) The Lead Investigator shall use the resources at their disposal to ensure a thorough and accurate investigation is undertaken. The Lead Investigator is responsible for producing a report detailing the investigation's findings and recommendations. All investigations shall be reviewed and approved in accordance with Table 5 Investigation review and approval matrix. (49) When developing corrective and preventative actions, key stakeholders, Health & Safety Representatives (HSRs) or other groups/agencies involved in the incident, must be consulted to ensure the threat or impact from the incident has been removed or reduced to an acceptable level. Recommendations not implemented as actions should be noted in the final report for consideration by the Incident Owner. (50) The Lead Investigator must propose recommendations to the investigation owner (as part of the final report) that will be designed to eliminate the hazard or reduce the risk of event re-occurrence. When developing actions, preference shall be given to physical controls rather than administrative controls, following the ‘Hierarchy of Controls’. Corrective and preventative actions shall be identified for all SIR events and recorded in RiskWare as per WHSMP17: WHS Action Management Procedure requirements. (51) Corrective or preventive actions must be assigned a due date and be the responsibility of a specific person to oversee the implementation. The incident owner is responsible for the monitoring of effectiveness and close-out of actions. Actions shall be tracked using RiskWare as per WHSMP17: WHS Action Management Procedure. Where actions cannot be closed on time request for extension should be sought from the relevant WHS person responsible for sign-off of the incident. (52) Evidence of implementation and completion of actions should be uploaded to RiskWare as part of the action close-out to provide evidence of completion and effectiveness. (53) Upon completion, investigations, recommendations, final report, and lessons learnt shall be presented to the investigation owner for sign-off. Once the investigation has been signed off it is then passed to the relevant person as per Table 5 for their review and approval. The review is to ascertain that a thorough investigation has been completed and that relevant actions to correct and prevent reoccurrence have been developed. (54) These reviews shall consider the following: (55) Post investigation completion and approval, a Just Culture review shall be conducted by the applicable Event Owner for SIR 1 & 2 classified events where it was identified with sufficient documented evidence that a destructive act, wilful violation or gross negligence may have been one of the contributing factors. SCU is committed to promoting a balance between the accountabilities of both the organisation and our leaders and team members in relation to the ownership of incident lessons learnt. (56) Embedded in the Just Culture Guideline is a process for the facilitation of a review of behavioural, process and systems aspects of an incident, which will guide the leader to a course of action and recommendations that are fair and consistent, and promote a culture of trust, openness and accountability. (57) Consultation with non-managerial workers should be undertaken during the investigation of incidents and non-conformities and determining corrective actions. They should form members of investigation teams and be consulted and communicated with throughout the entire investigation process where applicable. (58) The sharing of lessons learnt from unplanned events is critical to assist in the prevention of similar events across Work Units and the University. The communication of investigation outcomes following the review and approval of incidents shall be undertaken by the relevant person as per Table 5. At no time is it permissible to distribute the names of persons injured or killed or the extent of injuries identified for public release. (59) As a minimum, incident outcomes shall be communicated to the workforce via team and safety meetings, notice boards, information meetings and safety bulletins. The WHSMP17-FOR-02 Lessons Learnt Template outlines the elements required to be communicated however alternate document may be used provided the below elements are contained within: (60) All Investigation Reports and evidence shall be securely stored within RiskWare. All event investigation records and supporting evidence shall be maintained for a minimum of 7 years after the last action unless otherwise requested by external parties. Work Units shall ensure that all incident-related records are maintained in accordance with regulatory requirements, and WHSMP08: Document and Records Management Procedure. (61) The permanent disposal of hard copy records at the end of the mandatory period should be risk assessed for the potential future need. Verification that all documents have been correctly scanned and saved should be undertaken before the commencement of disposal. (62) All evidence collected during an investigation (e.g. interview statements, field notes, photos, maintenance records etc.) shall be scanned and uploaded into RiskWare. Incident notifications, investigation reports and corrective actions for all events are also to be entered in RiskWare. Unless required by legislation, a copy of the investigation report shall only be made available to the regulatory authority when a request is made in writing. (63) The privacy of injured or ill individuals or involved persons must be respected during the investigation process and when recording the investigation details into RiskWare. Information should be captured in a way including in the final report that does not personally identify those involved. Medical records must not be disclosed without written authorisation and medical details must remain confidential amongst the incident investigation team. All medical records are to be maintained in a secure online HR system. (64) All WHS incidents shall be recorded and managed through the SCU-mandated RiskWare system. Events classified as legal privilege will be only visible to the Governance team and those with approved permission settings in RiskWare. Where there are multiple outcomes from a single event (i.e. personal injury and environmental damage), outcomes will be entered into RiskWare separately and the individual events linked. (65) All personal injury events are to be logged in the RiskWare. All work-related injuries are to be recorded and managed in accordance with reference to the Injury Management Procedure. A copy of the completed incident report must be made available to the injured person if requested. (66) All employees and other relevant interested parties shall be trained in the requirement to report any incident or near-miss event to their immediate supervisor. All leaders shall be trained in the application of this Procedure, reporting events with those responsible for incident entry into RiskWare. (67) The below table outlines the training and competency requirements for employees with the potential to be involved in or manage incidents and investigations. (68) Ongoing monitoring and reviews through inspections and audits should be undertaken to ensure the effectiveness of any actions taken including corrective actions. When events occur, other subsequent Work Units should review their work to ensure that a similar event won’t transpire in a separate area of the University. (69) The ongoing application and effectiveness of this procedure shall be monitored through the review of incident investigations by the WHS Team. Unless otherwise triggered via an incident, process change, or other event, this procedure shall be reviewed at least every two years. (70) The SCU Council has the following WHS responsibilities: (71) The SCU Vice Chancellor has the following WHS responsibilities: (72) Vice Presidents/Pro/Deputy Vice Chancellors have the following WHS responsibilities: (73) The Head of the Work Unit has the following WHS responsibilities: (74) Managers and Supervisors have the following WHS responsibilities: (75) All employees have the following WHS responsibilities: (76) The WHS Manager has the following responsibilities: (77) WHS Business Partners have the following responsibilities: (78) All relevant documentation will be recorded and kept in accordance with WHS Legislation and other legislative obligations including: (79) This procedure will be reviewed as per nominated review dates or because of other events, such as: WHSMP17: Incident Management, Reporting and Investigation Procedure
Section 1 - Purpose and Scope
Section 2 - Definitions
Top of Page
Section 3 - General Principles
Incident or non-conformance definition
Event management
Immediate Action
Employee Assistance Program (EAP)
Event Classification
Event Reporting and Notifications
Internal Event Reporting
Internal SIRS 1 & 2
External Notifications
Notifiable Safety Incidents
Reporting in RiskWare
Incident Investigation Process
Resourcing of Investigation Team
Evidence Collection
Direct observations
Documents
Interview and Witness statements
Analysis of the information
Drawing conclusions
Incident investigation Reports
Development of Corrective and Preventative Actions
Investigation Review and Approval
Incident sign-off and approval
Lessons Learnt Corrective / Preventative actions
Lessons Learnt Corrective / Preventative actions
Just Culture
Communication and Consultation of Investigation Findings
Recording Events
Investigation Records Management
Injury Record Management
Training
Monitoring and Review
Section 4 - Roles and Responsibilities
University Council
Operational Responsibilities
Vice Presidents/Pro/Deputy Vice-Chancellor
Head of Work Unit
Managers and Supervisors
Employees
WHS Team
WHS Manager
WHS Business Partners
Top of PageSection 5 - Records of Documentation
Top of PageSection 6 - Revision and approval history
Top of PageSection 7 - References
Top of Page
Section 8 - Related Documents