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WHS G022 Incident Investigation Level 2 (ICAM) and SkyTrust Close-out Guideline

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Section 1 - Overview

(1) This guideline is to be utilised by university staff investigating Incidents reported by staff or students, to assist with conducting a Level 2 Incident Investigation recording the investigation and closing out of the Incident in Sky Trust. 

(2) WHS P007 Incident/Hazard Reporting and Investigation Protocol provides the strategic direction for investigating level 2 Incidents. 

(3) A level 2 incident is an Incident that is notifiable to the regulator of a ‘serious nature’ and the investigation should be conducted by a suitably trained ICAM investigator. 

(4) Training modules on Investigation are available on Skytrust via the SkyLearn icon. These training Guides provide assistance in general investigations and the uploading/recording of investigation information to the Incident Report. 

(5) When an Incident is reported by a staff member or student on SkyTrust a notification wil be sent to the WHS team. If an incident is deemed to be a Level 2, the WHS manager will engage an ICAM trained Investigator/s to conduct the investigation. 

(6) ICAM trained investigators will be appointed by the WHS Team and the incident will be recorded in the ICAM Register. The SkyTrust Investigation will be completed by the WHS Team with the ICAM Investigation brief attached. 

(7) ICAM Investigation documents are located in WHS F023 ICAM Level 2. 

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Section 2 - Scope

(8) This guideline, the Incident Investigation Level 2 (ICAM) & SkyTrust Close-Out Guideline is to be utilised by University Staff who are allocated the task of conducting an incident investigation. 

(9) This guideline is only to be used for Level 2 Incident Investigations. 

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Section 3 - Guideline

Investigation process – What to do and what information gather

(10) The steps in the table below are required to conduct an ICAM investigation, these processes would be completed and all information uploaded and recorded in the SkyTrust Incident Investigation. The WHS team will manage and record the investigation outcomes in Skytrust on behalf of the Investigator/s. 

Use the WHS F023 ICAM Level 2 Investigation Brief

(11)  

What action to take  What information to collect

Cover sheet
*Complete all sections
*ICAM reference number is to be supplied by the WHS Manager upon allocation of investigation. 

Contents
*Complete all sections
*Add all items at completion of investigation. 

Complete Investigation Plan
*Complete all sections
*Add all items gathered in the investigation

Complete the analysis and identification of Key Evidence – PEEPO
*P-People – who are the key people involved and what information/evidence do you require from each person – take a statement and record. 
*E-Environment – What  photos/observations/reviews/inspections are required of the scene or scenes?
*E- Equipment – What equipment was involved in the incident that requires review – testing, inspection or operation.
*P-Procedures – What procedures are relevant that require review.
*O-Organisation – What are the relevant, policies, training, supervision, governance.

Take Statements – Speak to the injured person or the person reporting the incident. 
*Make initial contact with the injured person and first ask them if they are okay and offer any support. 
*Tell them that you are conducting the investigation and that you require a written statement to be obtained. Determine a suitable location and time to take the statement and also inform the person’s supervisor of your intentions. 
*If the person is unwilling contact the WHS Manager. 
*Make some notes if required and retain as contemporaneous notes of the investigation.
*Record the statement using the questions below as a guide:
1. tell me what happened? Let the person freely explain their version of the event uninterrupted.
Use the probing questions below to establish further details.
2. What do you think caused the incident?
3. Was Equipment Failure a factor?
4. Was human error a factor?
5. What do you think could be done to prevent this type of incident occurring again?
6. Could you fully describe the work and conditions in progress, leading up to the incident?
7. Could you describe in detail the incident sequence from start to finish?
8. Did you notice anything unusual prior to, or during the incident (sights, sounds, smells etc.)?
9. What was your role in the incident sequence?
10. What conditions influenced the incident (weather,time of day, equipment malfunctions etc.)?
11. How did people influence the incident (actions, emergency response etc.)?
12. Were there any witnesses?
13. Do you have any additional comments about the incident?

Statements – Speak with any witnesses

 *Witness statements are completed using the same questions and recorded in the same way as the injured person, see above. 

Take photos – Visit the location of the incident. 
*Make observation of the location of where the incident occurred.
*Take photos and document in the photos section of the brief form. 

Obtain other documents if required
*Obtain any training records if applicable (e.g.records confirming authorised use of specific equipment, such as a power tool).
*Attach documents to the Investigation brief and record in the PEEPO analysis. 

Complete investigation Outcome Report. 
*Complete all sections
*Summarise the PEEPO information gathered

Identify any causes of the incident

 *Using the 5 X ‘Why’s’ you can identify the Root Cause/s of the incident, this can be done multiple times and recorded, in the Root Cause and Key Findings section. 

Determine any Remedial Corrective Actions and an Implementation Plan 
*After reviewing the information gathered make any determinations on what action/s are required. 
*Make the recommendations and allocate a primary support person responsible for the action. This may not be possible to determine, and WHS can assist. 

Sign the Investigation

 When the investigation is completed, sign off the report and forward to Section to sign off as complete. You can use the mouse to sign the signature box. 

Ask WHS for help

 If you get stuck or need assistance contact the WHS Team for help. 


Investigation record keeping and SkyTrust Close-out

(12) At the completion of the investigation the Investigation Brief document is to be forwarded to the WHS Manager. The Brief will be attached to the investigation in SkyTrust. At the completion of the Management Review and Acceptance of the recommendations the WHS Manager will record and allocate the recommendations as actions within the SkyTrust Investigation.