Auckland Transport

Incident reporting recording and investigation procedure

PRO-HS12-INC

  1. Background and Purpose

This procedure sets out the requirements and responsibilities to:

  • Report, record, and investigate incidents and near hits within Auckland Transport (AT) and its operations in a timely manner.
  • Ensure prompt assistance, guidance and training is provided to enable the timely management of incidents.
  • Provide a source of data that can be used to identify trends and underlying causes to prevent future incidents.
  • Ensure all statutory and regulatory reporting requirements are met in a timely manner.
  • Communicate any lessons learned to the appropriate audience.

Through the above, we will contribute to AT’s goal of a business-wide zero harm culture.

  1. Scope

This procedure applies to all AT employees, members of the public, visitors, and suppliers who may be affected by AT’s activities or who undertake activities on behalf of AT. It has been completed to align with Auckland Transport’s Health and safety framework. 

This procedure does not cover the reporting of sickness or disease (for management of sickness, absence, or for statutory reporting purposes).

This procedure is to be read in conjunction with the relevant AT Health and Safety Incident Management Standard and any associated guidance and training material.

  1. Responsibilities

Chief Executive

  • Is accountable for the organisation’s compliance with AT’s Health and Safety policies and standards including allocation of resources and accountabilities across the organisation to meet this Procedure.
  • Review the findings and trends from all incidents and investigations into Class 1 and 2 incidents.
  • Ensure there are processes in place to prevent and manage incidents.
  • Ensure there are competent persons within the organisation to undertake incident investigations to the levels relative to Incident Classes.
  • Ensure incidents are reported, investigated and managed in accordance with legislative and AT Health and Safety Standard guidelines.

Divisional Managers

  • Are accountable for ensuring that appropriately documented processes specified in this procedure are in place across their area of responsibility.
  • All incidents are reported and investigated in line with the requirements set out in this procedure and the relevant AT standard.
  • Will undertake monthly reviews of incident trends and, in consultation with the H&S Manager, put plans in place to prevent reoccurrences for their area of responsibility.
  • Ensure there are competent persons within their division to undertake incident investigations.
  • Ensure all corrective actions are closed out in a timely manner.
  • Communicate Lessons Learnt and Safety Alerts relevant to all incident investigations.

Health and Safety Manager

  • Ensure that AT’s Health and Safety Management System documentation includes minimum requirements and tools to support management in meeting their responsibilities.
  • Report all notifiable events to AT’s legal counsel and WorkSafe within the specification timeframes.
  • Ensure that all information gathered from incident investigations across Auckland Transport is analysed and reported to determine organisational and project effectiveness.
  • Develop strategies to improve performance standards, the Health and Safety Management System, and day-to-day practices.
  • Review investigation outcomes to share Safety Alerts/Lessons Learnt across Auckland Transport and with other stakeholders as appropriate.
  • Conduct governance programs to assess compliance with legislative, external and organisational requirements.

Line Managers

  • Report and investigate incidents, prioritising corrective or preventative action aimed at preventing recurrence of similar events.
  • Ensure safe systems of work are implemented and that all persons are trained, competent, and fit for the tasks they will undertake.
  • Ensure that, in the event of a Class 1 incident, systems are in place to notify key internal and external stakeholders within specified timeframes.
  • Ensure that, in the event of a Class 1 incident, work only recommences once all necessary approvals have been obtained.
  • Ensure that the effectiveness of the implemented control measures are reviewed post implementation.
  • Ensure self-assessments and declarations of compliance are undertaken annually.

Employees

  • Comply with the risk management controls for all work activities undertaken.
  • Only undertake tasks for which they have been trained and are authorised to undertake.
  • Report all incidents involving themselves or others that they are aware of in accordance with this standard and relevant procedure.
  1. Process

This process sets out the steps to reporting, recording, and investigating an incident.

 HS12 - Incident Reporting And Investigation Procedure (1)

  1. Procedure

5.1  Reporting

Internal Reporting

The following must be reported to the department manager responsible for the activity and through the completion of the online reporting tool, “Synergi Life”:

  • Notifiable events reportable under the Health and Safety in Employment Act 1992;
  • All incidents resulting in injury must be reported via the online reporting system, “Synergi Life”. This satisfies the requirements under the H&S Act and negates the requirement for an “incident register” or log;
  • Near hits, hazards, and incidents of any nature within the business;
  • All work-related Road Traffic Incidents (RTIs) should be reported using the same procedure (and also to the Procurement team for insurance purposes for company / lease vehicles);
  • Security breaches;
  • Damage to property or equipment;
  • Environmental incidents or near hits.

The report form must be submitted to your department manager and the H&S Manager within the time specified following an incident occurring.

Any fatality, major injury, reportable event, serious near hit or incident with the potential to cause significant adverse Public Relations (PR) are to be reported immediately to:

  • the Health and Safety Manager;
  • the Chief Executive and the Executive Leadership Team; and
  • the Chairman of the Board.

The following table (Incident Notification) sets out the minimum reporting timeframe requirements: 

Incident Notification Table 

Severity Level

Incident Classification

Notification Requirement
(to H&S Team)

Incident Report Form (to H&S Team)

Investigation Team

Investigation Report

(to H&S Team)

Class 1

Fatality/Death

Immediately upon identification

As soon as practicable within 2 hours

Divisional Manager & H&S Manager

- Lead Investigators

 

Technical Specialist

(case specific, i.e. engineer, occ health advisor)

10 Working days

Notifiable Event

Immediately upon identification

As soon as practicable within 4 hours

Department Manager

– Lead Investigator

 

H&S Advisor

 

Technical Specialist

(case specific, i.e. engineer, occ health advisor)

10 Working days

Serious Near Hit and/or Unsafe Event

Immediately upon identification but within the normal work day or shift period

As soon as practicable within 12 hours

Department Manager – Lead Investigator

 

H&S Advisor

 

Technical Specialist

(case specific, i.e. engineer, occ health advisor)

10 Working days

Class 2

Lost Time Injury

As soon as practicable but within 24 hours

Within 24 hours

Department Manager

- Lead Investigator

10 Working days

Medical Treatment/ Assessment

As soon as practicable and prior to attendance at medical practitioner, where practicable (within 24 hours)

Within 24 hours

Department Manager

- Lead Investigator

10 Working days

Class 3

1st Aid Injury

Within 24 hours

Within 24 hours

Department Manager

- Lead Investigator

10 Working days

Pain and Discomfort

Near Hit or Unsafe Event

In the event of a Class 1 incident, work will be suspended and shall not resume until an appropriate assessment of risk is undertaken and authorisation is given by the appropriate Executive, General Counsel, or Manager (outside the project/activity) in consultation with the Health and Safety Manager. 

All Health and Safety incidents shall be entered into the Auckland Transport Health and Safety online reporting system. All incidents, including those involving visitors and suppliers, must also be recorded in the internal online reporting system.

AT’s Drug and Alcohol Policy specifies that testing for the presence of drugs and/or alcohol may be conducted following an incident where there was actual or potential for serious harm, loss, or property damage. For more details, please see AT’s Drugs & Alcohol Policy and associated Process.

External Reporting

Notifiable events as defined in Schedule 1 of the NZ Health and Safety in Employment Act 1992 must be notified to Worksafe[1] NZ by the Health and Safety Manager as soon as possible after an incident has occurred with the notification form submitted within 7 days.

All notifiable events must be reported as soon as possible after occurrence and within 7 days of the incident by means of the WorkSafe Notifiable Events form. 

Following the notification, WorkSafe may require a written investigation report to be submitted. WorkSafe and other parties may wish to undertake an investigation themselves and require the site to be left untouched until this process is complete.

If an employee has an incident whilst carrying out work on/in a third party’s premises, they must notify the person in control of the premises in addition to following Auckland Transport’s reporting procedure.

Supplier Reporting

Suppliers carrying out work for or on behalf of Auckland Transport must report all incidents to their nominated contact, for example the Project Manager, who must notify the Health and Safety team and complete the AT online report. If the incident occurs on a non-AT site, then the representative for that site must also be notified.

The supplier will be required to complete an investigation, as per the requirements of this procedure, and submit an investigation report, within 10 days, to AT’s Health and Safety Manager. AT may choose to work with the supplier to ensure the investigation has been undertaken competently.

Exemptions or variations to the reporting requirements under this Procedure can only be approved by both the appropriate Supplier Manager and the Health and Safety Manager.

5.2 Investigation

All Class 1 and 2 Health and Safety incidents shall be investigated using an appropriate incident causation model approved by the Health and Safety Team.

The model shall include a process for identifying all the essential factors or root causes of the incident.

However, there will be, on occasion, incidents and events that occur where the prescribed level of investigation and reporting will provide little value to the organisation, or where the resource and effort required is not commensurate with the potential benefits. In such circumstances, an ‘exemption’ may be authorised by the Health and Safety Manager after a review of relevant facts, circumstances, and outcomes. This exemption shall take the form of a formal notification and cannot be delegated to another party.

The investigations shall be carried out by competent persons with involvement of relevant personnel and their representatives where required.

  • The level of detail of these investigations and the composition of the investigation team shall be appropriate to the Incident Severity Class.
  • Competent resources shall be provided to ensure that investigations are conducted to a standard that identifies all the essential factors and that lessons learnt are communicated promptly.
  • An AT nominated employee shall be part of any incident investigation arising from work being undertaken for or on behalf of Auckland Transport.

A full written investigation report using AT’s Health and Safety Incident Investigation Report template shall be submitted to the Health and Safety Manager within 10 working days of the incident. An ‘extension’ to this timeframe may be authorised by the Health and Safety Manager after a review of relevant facts, circumstances, and progress. This extension must be given in writing and cannot be delegated to another party.

Investigation Guidelines

  1. All Incident Classes involving AT employees and suppliers resulting from AT operations are to be investigated along with all work injuries.
  2. Each Division, with the support of the Health and Safety Manager, shall appoint a competent person to undertake an investigation should any of the aforementioned events occur.
  3. Photographs of the incident scene are to be maintained with the incident report where appropriate.
  4. All incident investigation reports are to include recommendations for any preventative action that became evident during the investigation.
  5. All incident investigation reports are to be reviewed by the H&S Manager and the relevant Department Manager and presented to the Chief Executive and the relevant Divisional Manager(s) as soon as practicable.
  6. All investigators of incidents are required to:
    1. Visit the incident scene for all Class 1 incidents before the physical evidence is disturbed.
    2. Take samples of any materials likely to have contributed to the incident (unknown chemical spills, residues, dusts, or other substances) noting conditions that may have affected the sample if applicable.
    3. Make comprehensive visual records. No one can predict in advance what data will be useful, so photographs should be taken from many different angles and complete, accurate sketches or diagrams should be made before the incident scene is restored.
    4. Determine which incident-related items should be preserved. This may become critical evidence if there is subsequent litigation.
    5. Identify the people who were involved in the incident. Also identify eyewitnesses, including those who saw the events leading to the incident, those who saw the incident happen, and those who came upon the scene immediately following the incident. It is important to accurately record witness statements’ as close to the time the incident occurred, which can be a valuable check against inconsistencies. Have the witness sign their statement as evidence of it being a true record of their statement.
    6. Review all sources of potentially useful information. These may include original design, design specifications, drawings, operating logs, purchasing records, previous reports, maintenance logs, procedures, verbal instructions, inspection and test records, alteration or change of design records, job safety analysis, records indicating previous training and job performance of the workers and supervisors involved.
    7. Complete an AT Health and Safety Incident Investigation Report outlining causal factors and detail corrective action including time frames for actions.
    8. Remember, investigations must be carried out in an objective manner and be based on facts, not opinion or workplace hearsay.

Recommendations, Corrective and Preventive Action

All incident investigations shall have corrective and preventative actions developed, implemented, and reviewed to address the findings from the investigation.

The results of any investigation, including recommendations and corrective actions, shall be communicated to all appropriate persons for actioning, included in the appropriate management review, and considered for continual improvement activities.

Safety Alerts or Lessons Learnt from investigations shall be communicated across Auckland Transport in accordance with Health and Safety Standard: Communication and Consultation. Please refer to the Health and Safety Alert Template for all urgent safety communications relating to incident investigation findings.

5.3 Information, Instruction and Training

Employees who may be involved in investigating serious and/or notifiable events must be trained in investigation skills and techniques to ensure that a competent investigation is carried out and robust and effective recommendations made.

Visitors, suppliers, and other non-employees must be made aware of the requirements of this procedure. Data on incidents and near hit trends will be made available to all staff via a monthly health & safety communication.

5.4 Trend Analysis

All incident and near hit data will be recorded on a central database and analysed for trends by the H&S team. Trend data will be reported to the Executive Leadership Team regularly.

Where trends are identified, investigation into causative factors will be undertaken to identify risk reduction measures and eliminate trends.

5.5 Documentation

The Health and Safety Team will retain all documents that are written, submitted and received in relation to statutory requirements along with any supporting information.

  1. Definitions

See H&S Definitions

Related standard

Incident Management