Incident, Near Miss and Safety Rule Breach Report Form
v2.4
Purpose. Workers complete this form to report injuries, electrical contacts, plant contacts with apparatus, falls, near misses, safety rule breaches, environmental incidents and hazards.
1.When to use this form
Use this form for every incident and near miss on a network site, in the rail corridor, in a depot or on the road, including safety rule breaches you observe. Phone the network controller and your team leader immediately for any electrical contact, plant contact with apparatus, fall, injury or fire, then complete the form before the end of the shift.
2.Electrical events
For any electrical contact, flashover or plant contact record the apparatus and voltage, whether an access authority was held and its number, the isolation and earthing state, the safe approach distance involved and the names of the access recipient and controller. These events are notifiable to the regulator and the client.
3.Describing the event
Record what happened in sequence with the times, the equipment and plant involved, the weather and site conditions and the names of witnesses. Record facts, not opinions about cause.
4.Team leader section
The team leader records the immediate actions, whether the site was made safe and preserved, whether the client and regulator were notified, and the initial risk rating, and forwards the form to the Network Operations, Safety and Training Manager within one business day.
5.Privacy
Personal information on this form is used only to manage the incident and meet legal obligations and is stored in the safety records with restricted access.