Ezdihar Al-Garraf Company

Incident Investigation Procedure

Document Owner: EGC- SQA -103-A0

Rev B Official Release Date: 25th /Dec /2017

APPROVED:

________________________________
Date
Karrar Al_Bahadly
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Contents

1. Purpose ........................................................................................................................ 3

2. Scope ........................................................................................................................... 3

3. Roles and responsibilities .......................................................................................... 4

4. Procedure .................................................................................................................... 7
4.1 Incident Response .............................................................................................. 7
4.2 Preserve the incident scene ................................................................................ 7
4.3 External notification to regulators ........................................................................ 8
4.4 Investigation planning ......................................................................................... 8
4.5 Data collection .................................................................................................... 9
4.6 Interim investigation summary ........................................................................... 11
4.7 Data organization and analysis ......................................................................... 11
4.8 Developing recommendations, actions, key learnings and reports .................... 12

5. Training requirements .............................................................................................. 13

6. Record keeping ......................................................................................................... 13

7. Monitoring and audit ................................................................................................. 13

8. References ................................................................................................................. 14
8.1 Legislation and other requirements ................................................................... 14
8.2 Supporting procedures ...................................................................................... 14
8.3 Supporting documents, forms and templates .................................................... 15

9. Definitions ................................................................................................................. 15

Appendix A - Incident investigation flowchart ................................................................. 19

Appendix B - Investigation matrix ..................................................................................... 20

Appendix C – Sample Causes ........................................................................................... 21

Appendix D – Notifiable Incident Definitions ................................................................... 24

WHS Notifiable incidents ............................................................................................. 24
-Dangerous electrical event ......................................................................................... 24
-Dangerous incident .................................................................................................... 24
-Serious bodily incident ............................................................................................... 25
-Serious electrical incident ........................................................................................... 25
Environmental Breaches ............................................................................................. 25

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1. Purpose
‘Ezdihar Al-Garraf’ Company is committed to continuous improvement within our
business. The purpose of this procedure is to standardize processes and
responsibilities in relation to the notification and investigation of incidents with the
aim of ensuring:
• incidents are investigated to the extent necessary, to determine the root causes
and contributing factors, and to identify actions which aim to:
- eliminate or minimize identified hazards or risks as far as reasonably
practicable
- prevent reoccurrence of incidents
- imbed ‘Ezdihar Al-Garraf’ Company values
- challenge work processes that need improvement.
• Investigations should be conducted in a manner that provides a consistent
approach, with assurance that any recommendations are actionable and based
on reliable evidence.

2. Scope
This procedure applies to all incidents notified under Emergency
Management Manual work activities within ‘Ezdihar Al-Garraf’ Company.
The incident investigation methodology to be used by ‘Ezdihar Al-Garraf’ is based
upon the Incident Cause Analysis Method (ICAM).

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3. Roles and responsibilities

Term Definition

Managing Director • Promote a continuous improvement culture by facilitating

processes to investigate incidents that view human errors,
process failure or component failure as an opportunity to
learn
• Review findings from investigation reports to ensure as far
as reasonably practical that recommendations are
appropriate and adequately address improvements to the
identified risk(s)
• Review and approve the classification of High Potential
Incidents in consultation with relevant managers and
subject matter experts (SMEs)
• Allocate appropriate resources to investigate assigned
incidents within designated timeframes
• Approve investigation report findings within their area of
responsibility
Managers • Promote a positive culture by supporting processes around
investigations being conducted in a manner which views
human errors as an opportunity to learn
• Communicate with workers regarding the investigation
process outcomes, including key lessons learnt through
incident investigations
• Provide appropriate resources to adequately investigate all
incidents within designated timeframes.
• Make recommendations to the General Manager in relation
to the classification of High Potential Incidents in
consultation with the SME Manager
• Consult with lead investigators around following this
procedure to guide consistent incident investigation
outcomes.
Team • Where a notifiable or high potential incident has occurred,
Leader/Supervisor ensure as far as reasonably practical that the incident
scene is preserved and any emergency response taken to
control the incident is documented
• Support affected personnel and prevent reoccurrence
following an incident
• Participate and actively contribute to the investigation
process as required
• If required, direct workers involved in the incident to be
tested for substance use in accordance with the Managing
Alcohol and Other Drugs Procedure (PRO-01105)
• Provide workers involved in the incident or investigation
processes with Employee Assistance Program (EAP)
support as required
• Communicate information in relation to key learning’s to
staff and actions identified through incident investigations.

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Term Definition
Subject Matter Expert • Appoint an appropriately qualified incident investigation
(SME) Manager team in consultation with the relevant General
Manager/Manager as per Appendix B
• Utilize risk wizard to capture the incident investigation
outcomes enabling analysis of incidents, contributing
factors, corrective actions and effective risk analysis
• Where appropriate, seek legal advice from Ezdihar Al-Garraf
legal services team prior to commencing, or at any
necessary stage of the investigation
• Understand competency requirements for personnel
involved in incident investigations including training in
ICAM methodology and Ezdihar Al-Garraf incident
investigation requirements.

• Report investigation findings to the relevant manager and

responsible general manager
• Communicate incident investigation outcomes to Executive
Leadership Team, Board and other stakeholders as
required
• Monitor and verify the close-out of corrective actions
Subject Matter Expert • Appoint an appropriately qualified incident investigation
(SME) team in consultation with the relevant Manager/Team
Coordinator/Principal Leader in accordance with Appendix B
• Consult with lead investigators around following this
procedure to guide consistent incident investigation
outcomes
• Seek legal advice where appropriate with Ezdihar Al-Garraf’ legal
services team prior to commencing, and at any necessary
stage of the investigation
• Report investigation outcomes to the responsible
Manager/Team Leader within agreed timeframes
• Maintain and administer a database of incident
investigation outcomes enabling analysis of incidents,
contributing factors, corrective actions and effective risk
analysis
• Monitor and verify the close-out of corrective actions

Lead Investigator • Conduct and lead the investigation in accordance with this
procedure
• Lead the investigation to determine the immediate and
underlying causes
• Compile the investigation report using the recommended
template as per Appendix B and file in Ezdihar Al-Garraf
records management system (TRIM)

• Review documented recommendations with the relevant

Manager/Team Leader so that all are accepted and agreed

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Term Definition
to by the relevant parties
• Submit the investigation report within the allocated
timeframe
• Record investigation outcomes in risk wizard to enable the
analysis of incidents, contributing factors, corrective
actions and effective risk analysis
• Report findings to relevant persons as per Appendix B
Investigation team • Actively participate in the investigation process and take
members reasonable direction from the lead investigator.
Workers • Participate in incident investigations
• Participate in testing for alcohol and other drugs in
accordance with the Managing Alcohol and Other Drugs
Procedure
• Cooperate and assist with implementation of improvement
actions ensuing from investigations

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4. Procedure
4.1 Incident Response
The first person aware of an incident must act, where safe to do so, to
prevent further harm to people, product quality or supply, the environment,
property, reputation or a combination of these, and then must:
• immediately notify the relevant Team Leader/Manager
• immediately telephone Ezdihar Al-Garraf Incident Hotline (0783270 4040)
• preserve the incident scene (refer to section 4.2 specific details)

The responsible Team Leader/Manager upon being notified of the incident

shall provide direction to staff to complete the following actions:
• assess the situation and provide assistance and resources where necessary
• confirm that appropriate action has been taken to the extent practicable to
prevent further harm
• determine the actual and potential severity of the incident and notify
the Incident Hotline and other relevant stakeholders
• follow the relevant incident and emergency response plan (IERP) when it is an
emergency
• where a notifiable or high potential incident has occurred, preserve the
incident scene to obtain any relevant evidence (refer to section 4.2 for
more details)
• document any initial response taken to control the incident
• if required, direct workers involved in the incident to be tested for substance
use in accordance with the Managing Alcohol and Other Drugs Procedure
and offered Employee Assistance Program (EAP) support.

4.2 Preserve the incident scene

Preserving the incident scene enables the collection of evidence to ensure the
outcomes of the investigation are factual and enable the identification of causes.
In the case of a notifiable or high potential incident, the first person aware or any
other worker involved must facilitate events at the incident scene so that equipment,
plant, process, machinery or other associated plant connected with the incident are
not disturbed without the permission of the manager or regulator
(WHS/Environment). This does not prevent any action:
• to assist an injured person
• to allow an authorized person to remove a deceased person
• to make the site safe or to minimize the risk of a further notifiable incident
• that is associated with a police investigation
• for which an inspector or the regulator has given permission
• to preserve environmental protection
• to maintain water quality for downstream distribution
Work must be stopped until the risk of another or further incident is determined
and hazards and risks are managed so far as reasonably practicable.

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As soon as possible, capture critical information to facilitate the accurate reporting

and investigation of the incident. Examples of critical information may include, but is
not limited to:
• the full names of persons involved in the incident
• the exact nature of injuries, property damage, process failure/disruption
or environmental harm sustained
• statements from persons involved in the incident, including a clear description of
the sequence of events leading up to the incident (witness statements should be
recorded on a (Incident Witness Statement Form)
• details of any plant or property involved in the incident, including
registration numbers of third party vehicles involved
• photographs of the incident scene and/or associated property damage
• process/control system data
• contact details and/or statements from eye witnesses or third parties involved

4.3 Legal & professional privilege

Legal Services should be consulted to consider whether any material generated as
part of an investigation should be made under the protection of legal professional
privilege (LPP). Please contact Legal Services for advice around determining if
specific records from incidents should come under the LPP umbrella.

4.4 Investigation planning

4.4.1 Determine the level of investigation

Each incident shall be assessed against the actual and potential consequence as per
the Investigation Matrix (Appendix B). This assessment will be done in consultation
with the appropriate responsible party/SME as outlined in Appendix B to determine
the level of the investigation to be completed. Included are required documentation
templates for reports appropriate to the level of investigation.

4.4.2 Investigation team

A lead investigator and an investigation team (where required) will be appointed by
the responsible party as per Appendix B. The composition of the investigation
team should be commensurate with the actual and potential of the incident so as to
be able to determine root causes, contributing factors and identification of
appropriate corrective and preventive actions.

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4.4.3 Investigation planning

The objectives of planning are to establish the scope, means and timeframes of the
investigation, identify the resources and tools required for investigation and to
assess and control the risks associated with the investigation activities.
The investigation team will develop an action plan for each investigation which
includes plans to collect information from within the following categories:
• People – information relating to witnesses and personnel associated with
the incident
• Environment – information relating to weather, workplace, incident scene.
• Equipment – information relating to vehicles, plant, tools, infrastructure etc.
• Procedures – information relating to documents, reports, charts, maps etc.
• Organization – information relating to training, communication,
resources, organizational culture and management etc.

4.5 Data collection

4.5.1 Inspection of the incident site

An inspection of the site should be undertaken as soon as practicable after the

incident. Prior to conducting the inspection, the investigation team will complete a
Real Time Hazard Assessment (RTHA) for each work area and each type of
activity to assess and manage the hazards and risks in gathering evidence.
All conditions (at the time the incident occurred) shall be assessed during
the inspection including but not limited to:
• position of equipment, instrumentation and control switches
• illumination, visibility and audibility
• gouges, scratches, smears, discolouration, burn marks, spills
• the effects or condition of the weather
• presence or absence of signage
• excessive force used
• equipment failures
• loss of any containment
• condition of equipment
• process and other operations data.

4.5.2 Records
Video cameras, still photography cameras and sketches may be used to assist with
recording the scene. When taking photos or video footage the time and location
must be documented. The Incident Investigation Photograph Log may be used for
this purpose. Consideration must also be given to personal privacy when collecting
evidence, with permission sought to collect, store and use private information
including images.

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In addition, individuals should be advised of the reason and scope of use of the private
information including where it will be stored and who will have access to it. The
investigation team should review the relevant documents or parts of documents
collected during the investigation and reference their use. Record appropriate dates
and times associated with the incident on the documents reviewed.

4.5.3 Interviews and statements

Any written statements from witnesses involved may be recorded using the Incident
Witness Statement Form .
Private interviews must be conducted so that:
• confidentiality of any personal information obtained is maintained and any limits
to confidentiality are explained
• the interviewee is not pressured into providing a statement or information
• the interviewee may invite other persons to attend the interview such as a work
colleague, union representative or safety representative
• the location of the interview is suitable and free of interruptions
• leading questions are not asked and the interviewee is not prompted for answers
• objectivity is maintained
• vague generalizations are avoided and information discussed is specific to what
was witnessed.

4.5.4 Evidence collection and storage

The investigation team shall coordinate the collection, labelling, and preservation of
physical evidence. All evidence must be documented and stored together in a
secure location to allow for retrieval. The Incident Investigation Evidence Log may
be used for this purpose.
The relevant line manager or site supervisor must establish a quarantine area
for any failed equipment or components and tag or label all failed equipment or
components as ‘out of service’ as per the Energy Tag and Lock Out Procedure.

4.5.5 Final considerations

Once all the data is collected from the incident scene and before the scene is
released back to the relevant owner/operator, the following should be considered by
the lead investigator:
• all options for gathering information have been exhausted
• all other concurrent investigations are not affected
• communication of any residual hazards should occur
• input has been considered from all SMEs.

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4.7 Interim investigation summary

In order to keep key stakeholders informed an interim investigation summary (see
Appendix B) constituting the accurate and objective record of the incident and
confirmation of the initial incident notification provides preliminary details on the
following:

• who was involved

• the location of the incident
• what actually occurred
• when the incident occurred and may include a timeline of significant events that
may have occurred leading up to the event
• initial actions to remedy the incident
• details of key evidence reviewed and collected
• preliminary causal factors
Further investigation will continue but the summary should be sufficiently detailed
for a reader to understand the incident and the basis of any initial proposed
improvements. Based on the initial findings, it may be necessary to reassess the
incident level and investigation requirements as per Appendix B.

4.8 Data organization and analysis

4.8.1 Assess for consistency

The investigation team must review and verify the data to ensure accuracy
and objectivity. The initial information obtained should then be organized into
the following categories:
• people – information relating to witnesses and personnel associated with the
incident.
• environment – information relating to weather, workplace and incident scene.
• equipment – information relating to vehicles, plant, tools, infrastructure etc.
• procedures – information relating to documents, reports, charts, maps etc.
• organization – information relating to training, communication, resources,
organizational culture and management etc.

4.8.2 Analysis of contributing factors

Following the collation of all facts related to the incident the factors that contributed
to the incident must be identified. Appendix C provides a guide on investigation
outcomes that can be considered around non-contributing factors, absent/failed
defences, individual/team actions, team/environmental conditions and
organizational factors. Upon identification of the findings, recommendations for
corrective and preventive actions are to be developed.

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4.9 Developing recommendations, actions, key learnings and reports

4.9.1 Identifying corrective and preventive actions

All recommendations identified from the investigation need to be documented in the

investigation report. The lead investigator will provide recommendations for
corrective and preventive actions to address absent or failed defenses, individual or
team actions, task or environmental conditions and organizational factors. These
will include corrective or preventive actions required to prevent a reoccurrence of
the event as per Non-Conformance, Corrective Action and Continuous Improvement
Procedure. These actions must address each of the contributing factors identified,
which will give effective long and short-term control measures.
In determining recommendations for corrective and preventive actions, the
hierarchy of controls must be considered. The investigation team should consider
recommendations that are:
• specific to the incident
• have implications for the site
• have implications for other areas
• do not introduce any new hazards.
A review of the documented recommendations will be conducted by the lead
investigator, their manager and the relevant Managers/Team Leaders including the
asset manager to discuss and agree on all proposed corrective and preventive
actions.
The timeframes for close-out of proposed actions by responsible Managers/Team
Leaders should also be agreed upon by all parties and documented. Timing and
priority will be based on the risk of reoccurrence involved. Workers should be
consulted in determining the recommended actions and solutions where required.

4.9.2 Incident investigation report

The lead investigator must follow the requirements of Appendix B for the incident
investigations’ report template, review specifications, and approval. The incident
investigation report constitutes an accurate and objective record of the incident
and provides complete and accurate details and explicit statements of:
• the investigation team’s investigation process
• facts pertaining to the incident
• analytical methods used and their results
• findings of the investigation team, including the causal factors of the incident
• agreed recommendations and associated preventative and corrective actions to
prevent recurrence of the incident
• key learnings.

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4.9.3 Data recording & communication of key learnings

The corporate electronic database will capture relevant information in relation to

the incident, for example; incident levels, mechanisms of incident, related risk
category, contributing factors and actions for recording and analysis.
Key learnings should be communicated to identified stakeholders through the
most appropriate process, for example; toolbox talks, meetings, emails etc.

5. Training requirements
Training will be provided in accordance with the Training and Competency
Management Procedure. Minimum training requirements are:
• lead investigators must complete an ICAM Lead Investigator Course.
• members of an investigation team should have completed an ICAM Basic
Investigators Course. This training will also allow these people to undertake the
role of Team Leader for investigations of minor or insignificant incidents. Each
business group will identify roles within their area to attend this training.
Managers will confirm through the MAP process relating to specific roles that there
are adequate numbers of trained lead incident investigators within ‘Ezdihar
AlGarraf. These investigators must undertake appropriate training in the application
of the ICAM incident investigation methodology.

6. Record keeping
All records are to be retained, archived and disposed of in accordance with the
Archives General Retention and Disposal Schedule for Administrative Records and the
‘Ezdihar Al-Garraf’ Retention and Disposal Schedule QDAN717.All incident
investigation reports, including supporting documentation must be saved in TRIM, with
appropriate security that limits access to the record to:
• the incident investigation team
• the SMEs coordinator and manager
• the Manager, Supervisor and Team Leader for the area in which the
incident occurred
• Legal Services.

7. Monitoring and audit

The requirements of this procedure may be audited in accordance with the
Integrated Management System Internal Audit Procedure .
Analysis of investigation outcomes will be undertaken as part of yearly management
review using the corporate electronic database and reviewed at regular intervals in
conjunction with the scheduled risk register and risk profile reviews.

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8. References
8.1 Legislation and other requirements

Description Status Location

Electrical Safety Act 2002 (Qld) Active www.legislation.qld.gov.au

Electrical Safety Regulation 2013 (Qld) Active www.legislation.qld.gov.au

Work Health and Safety Act 2011 (Qld) Active www.legislation.qld.gov.au

Work Health and Safety Regulation Active www.legislation.qld.gov.au

2011 (Qld)

Environmental Protection Act 1994 (Qld) Active www.legislation.qld.gov.au

Environmental Protection Regulation Active www.legislation.qld.gov.au

2008 (Qld)

Water Supply (Safety and Reliability) Act Active www.legislation.qld.gov.au

2008 (Qld)

WHS Standard AS/NZS 4801 Active www.saiglobaliso.com/online

Environmental Standard ISO 14001 Active www.saiglobaliso.com/online

Quality Standard ISO 9001 Active www.saiglobaliso.com/online

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9. Definitions
Term Definition
Absent or failed defences The situations, systems, conditions, equipment, measures
or human factors that normally prevent this type of incident
from happening.
Control A control is any measure or action that modifies risk.
Controls include any policy, procedure, practice, process,
technology, technique, method, or device that modifies or
manages risk.
Corporate Electronic Risk Wizard will be used for all incidents and associated
Database investigations received through OCA as a result of the
2016 Risk Wizard implementation throughout the business.
Effective control (WHS) The meaning of an effective control includes fit for
purpose, being suitable for the nature and duration of the
work and installed, set up and used correctly.
Emergency An event that happens as a consequence of an incident
and demands immediate action. It is the broader
coordination to manage incidents including mitigation and
public and stakeholder outcomes.
First aid injury Any once-off treatment and/or subsequent observation of
minor scratches, cuts, burns, splinters, etc. which do not
require professional medical treatment. However, in some
instances, a medical practitioner or registered professional
may administer the first aid as follows:
− Tetanus injection or precautionary antibiotics.
− Application of antiseptics during first visit to medical
personnel. Application of ointments to abrasions to
prevent drying or cracking.
− Treatment of first degree burn(s).
− Application of bandages(s) during any visit to medical
personnel.

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Term Definition
− Use of elastic bandage(s) during first visit to medical
personnel.
− Removal of foreign bodies (not embedded) in eye if
only irrigation is required.
− Removal of foreign bodies from wound if procedure is
uncomplicated, and is for example, by tweezers or
other simple technique.
− Use of non-prescription medications and
administration of single dose of prescription medication
on first visit for minor injury or discomfort.
− Application of hot or cold compress during first visit to
medical personnel.
− Negative X-Ray taken to confirm the existence or
otherwise of a diagnosed condition.
Hazard - WHS/Environment A situation that has the potential to harm a person and/or
the environment and/or damage property etc.
Hazard – Water Quality A hazard is a biological, chemical, physical or radiological
agent that has the potential to cause harm or be
aesthetically unacceptable to the consumer.

Hazardous Water Quality A hazardous event is an incident or situation that can lead
Event to the presence of a hazard.
Hierarchy of controls Identify the risk control actions and responsibilities by
identifying controls in the following specific order:
• Eliminate the hazard.
If elimination of the hazard is not reasonably practicable,
minimise the risk so far as reasonably practicable by:
• substituting (wholly or partly) the hazard giving rise to
the risk with something that gives rise to a lesser risk
• isolating the hazard from any person exposed to it
• implementing engineering controls.
If a risk then remains, then minimise the remaining risk, so
far as is reasonably practicable, by implementing
administrative controls.
If a risk then remains, then minimise the remaining risk, so
far as is reasonably practicable, by ensuring the provision
and use of suitable Personal Protective Equipment (PPE).
High Potential Incident (HPI) An incident where the actual or potential risk rating is
assessed as “Extreme” or “High”.
Incidents that have been classified as a Near Miss may
also be deemed as HPI’s. In determining the actual and
potential risk, consideration should be based on the
reasonably foreseeable outcomes given the circumstances
and controls in place at the time of the event.
Confirmation of HPI classification is subject to consultation
with the Executive Leadership Team.
Incident Any occurrence that has resulted in adverse and
unplanned consequences to water supply, water quality,
people, the environment, property, reputation or a
combination of these.

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Term Definition
Incident Cause Analysis The ICAM process is an industrial safety analysis tool that
Method (ICAM) sorts the findings of an investigation into a structured
framework.
An ICAM analysis clarifies why the incident happened and
identifies all the factors that contributed to the event. The
contributing factors are classified into four categories of the
ICAM Model which are: absent or failed defenses,
individual or team actions, task or environmental factors,
and organizational factors.
Individual or team actions The errors or violations made by people directly involved in
the event.

Lost time injury (LTI) A work-related incident that results in an injury or illness
and time lost from work of one day/shift or more.
Medically treated injury An incident which results in the consequence of an injury
(MTI) to a person requiring treatment by, or under the order of, a
qualified medical practitioner, or treatment of any injury
that could be considered as being one that would normally
be treated by a medical practitioner.
Near miss Any unplanned incident that occurred at the workplace
that, although not resulting in any impact, had the potential
to do so.
Note – A near miss may also be a notifiable incident in
accordance with the definition of the term.
Notifiable incident or near An incident that requires notification to a regulator and is
miss determined following consultation between the SME
Manager and the responsible manager in accordance with
the Corporate Delegations and Authorisation Manual
(MAN-00076).
Refer to Appendix D for specific WHS incident types to
require notification to the regulator.
Organisational factors The latent system-based factors present before the
incident which may have contributed to the presence of
specific adverse task/environmental conditions,
individual/team actions or absent/failed defenses.
Preventive action Any action to eliminate the cause of a potential non-
conformity or other undesirable potential situation.
Reasonably practicable The following criteria must be applied in determining what
is reasonably practicable:
• What the person knows or ought to reasonably know
about the hazard and ways of eliminating or minimizing
the hazard
• Availability and suitability of ways of eliminating or
minimizing the hazard
• The cost associated with the eliminating or minimizing
the hazard, if it is grossly disproportionate to the risk.
Regulator The relevant statutory authority.
Responsible Manager/ Relevant Manager or Team Leader who is responsible for
Team Leader the activity, area or function in which the incident has
occurred.

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Term Definition
The effect of uncertainty on the ability of Ezdihar AL-Garraf
Risk to achieve its objectives.

Risk – Water Quality The likelihood of identified hazards causing harm in

(ADWG) exposed populations in a specified timeframe, including
the severity of the consequences.

Risk control (WHS) Means taking action to eliminate risks so far as is

reasonably practicable, and if that is not possible,
minimizing the risks so far as is reasonably practicable.
Eliminating a hazard will also eliminate any risks
associated with that hazard.
Root cause A root cause is the most basic reason for an incident,
which if corrected would prevent reoccurrence of the
incident.
Subject Matter Expert (SME) A person who manages a team of subject matter experts
Coordinator/Principal and reports to a SME Manager, this may include; WHS
Coordinator, Principal Environmental Management,
Principal Drinking Water Quality Management, Principal
Engineer Analysis and Advice, Principal Asset
Sustainability, Principal Process Engineering &
Improvement, Operations Coordinators, Asset
Maintenance Services Coordinator or other similar roles.
Subject Matter Expert (SME) A person who manages a team of subject matter experts
Manager and reports to a general manager, this may include WHS,
Environment, Asset Capability and Sustainability, Drinking
Water Quality or other similar functions.
Task or environmental The situational characteristics which existed immediately
conditions prior to the Incident, including the work situation, physical
or social environment, or a person's mental, physical or
emotional state.
Team leader A person who is responsible for leading a team of workers,
who is not a manager or general manager. Examples of
this may be an Operations Supervisor, Senior Dam
Operator, Senior Field Ranger, Coordinator or Principal.
Worker Worker means a person who carries out work in any
capacity for Seqwater, including work as:
• an employee
• a contractor or subcontractor
• an employee of a contractor or subcontractor
• an employee of a labor hire company who has been
assigned to work at Ezdihar AL-Garraf.
• an outworker
• an apprentice or trainee
• a student gaining work experience
• a volunteer
• a worker of a prescribed class.

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Appendix A - Investigation flowchart

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Appendix B - Investigation matrix

Incident category/ WHS Category Description Environment Category Water Quality Category Water Supply Category Lead Timeframes for Incident Incident
level Description Description Description Investigator investigation/Report type investigation investigation report
Appoint By reports to be approved by
provided to

Single or multiple fatalities Actual or potential Complete HACCP Critical Control Unplanned loss of water Responsible Within 60 working days Responsible Managing Director
widespread environmental Point failure - WQ product safety supply from any bulk General General Manager,
harm/Impacts to the cannot be determined. water supply point to any Manager in Responsible
ecosystem, flora, fauna non-network or network consultation Interim summary provided Managers, Legal
Potential for acute health impacts within 5 working days of
requiring extensive (potential for declared outbreak). connected supply zones with responsible Services
resources to mitigate (>6 for > 24 hours. Managers /SME becoming aware of the
Catastrophic EMT stood up. incident
months). Manager

TEM-00025 –Incident Report

Template

Permanent injury or impairment Localised on/off site actual or Complete HACCP Critical Control Unplanned loss of water Responsible 30 working days General Manager, Responsible General
potential serious Point failure - WQ product safety supply from any bulk General SME Manager, Manager
harm/Impacts to the cannot be determined. water supply point to any Manager in Responsible
ecosystem, flora, fauna non-network or consultation Interim summary provided Manager
Potential for acute health impacts within 5 working days of
(including declared and rare (no declared outbreak expected). connected customers with responsible
threatened and vulnerable supply zones for up to 24 Managers/SME becoming aware of the
Major species) requiring substantial EMT stood up. hours Manager incident
resources to mitigate (>3
&<6 months). TEM-00025 –Incident Report
Template

Moderate injury or temporary Localised on/off site actual or Repeated or elevated result above Reservoir levels below Responsible 20 working days Responsible Responsible Manager
impairment. One or more entire potential environmental ADWG value / specification for communication trigger manager in Manager,
shift missed as a result harm/impact to the chronic health parameters. levels > 8 hours. consultation SME Manager
ecosystem, flora, fauna Reduced operating with SME Interim summary provided
Repeated HACCP Critical or Action within 5 working days of
(excluding declared and rare Limit exceedence - WQ product still volumes due to treatment Manager
threatened and vulnerable plant capability for a short becoming aware of the
Moderate in specification but extensive incident
species) requiring limited corrective action taken place. duration resulting in
resources to mitigate (>1 - retailer network
Exceedence of Bulk Water Supply
<3 months). configuration changes. FRM-00094 –Incident
Agreement or ADWG aesthetic level
with potential for or actual Investigation Form
widespread customer impact.
Minor temporary injury or illness Localised on/off site Isolated result above ADWG value / Reservoirs approaching Responsible 10 working days SME Responsible Team
requiring medical treatment. environmental nuisance. specification for chronic health agreed communication Team Leader in Coordinator/Princip Leader
Inability to complete rest of shift Routine short term parameters. trigger levels. Treatment consultation al, Team Leader
or modified duties. remediation (<1 month). Repeated HACCP Critical or Action plant at restricted output with SME
requiring supply Coordinator/Prin FRM-00094 –Incident
Limit exceedence - WQ product still
Minor in specification & process controlled reconfiguration. cipal Investigation Form
as per HACCP Plan. No loss of supply from
any bulk water supply
Exceedence of Bulk Water Supply
point.
Agreement or ADWG aesthetic level
with potential for or actual customer
impact.
Symptoms requiring no treatment Localised, on site, actual or HACCP Critical Limit or repeated Reservoirs lower than SME 5 days SME SME
of first aid treatment only. potential nuisance. Routine Action Limit exceedence - WQ agreed normal operating Coordinator/Prin Coordinator/Princip Coordinator/Principal,
Returned to full duties short term remediation. product still in specification & levels for <4 hours or cipal al, Team Leader Team Leader
process controlled as per HACCP restricted output from Corporate Electronic
Insignificant Plan. treatment plant. No loss Database
Exceedence of Bulk Water Supply of supply from any bulk
Agreement level without customer water supply point.
impact. Little or no disruption to
normal operations.

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Appendix C – Sample Causes

Absent of failed defenses
Detection systems/
DF1 Absent Failed DF8 PPE Absent Failed
procedures
Protection systems/
DF2 Absent Failed DF9 Hazard identification Absent Failed
procedures
Warning systems/
DF3 Absent Failed DF10 Risk management Absent Failed
procedures

DF4 Guards or barriers Absent Failed DF11 Safe work procedure Absent Failed

Recovery systems/
DF5 Absent Failed DF12 Supervision Absent Failed
procedures
Escape systems/
DF6 Absent Failed DF13 Other: Absent Failed
procedures
Rescue systems/
DF7 Absent Failed DF14 Other: Absent Failed
procedures
Code State details for the identified defences that contributed to the event

Individual/team actions
Absent Inadequate Equipment/material Inadequate
IT1 Supervision IT8
Unsuitable handling Unsuitable
Absent
Absent Inadequate
IT2 Authority IT9 Horseplay Inadequate
Unsuitable
Unsuitable
Absent
Absent Inadequate
IT3 Operating speed Unsuitable
IT10 Hazard recognition Inadequate
Unsuitable
Absent Misuse Absent
IT4 Equipment use Exceeded limits IT11 Hazard management Inadequate
Unsuitable Selection Unsuitable
Absent
Absent
Exceeded limits
IT5 PPE IT12 Work method Inadequate
Misuse
Unsuitable
Unsuitable Selection
Partially Absent
Work procedure Occupational hygiene
IT6 Not followed IT13 Inadequate
followed practices
Unsuitable Unsuitable
Absent Inadequate
IT7 Change Management IT14 Other: Absent Failed
Unsuitable

Code State details for the identified individual/team actions that contributed to the event

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Task / Environment Factors

Workplace Factors Human Factors Impact
Task planning / preparation / Some Complacency /
WF1 HF1 Some Significant
manning Significant motivation
Hazard analysis / JSEA / Some Drugs / alcohol
WF2 HF2 Some Significant
RTHA Significant influence
Some
WF3 Work procedures HF3 Familiarity with task Some Significant
Significant
Some
WF4 Permit to work HF4 Fatigue Some Significant
Significant
Some
WF5 Abnormal operation HF5 Situational awareness Some Significant
Significant

Some Time / productivity

WF6 Tools / equipment HF6 Some Significant
Significant pressures
Material availability and Some
WF7 HF7 Peer pressure Some Significant
suitability Significant
Some
WF8 Equipment integrity HF8 Physical capabilities Some Significant
Significant
Some
WF9 Housekeeping HF9 Mental capabilities Some Significant
Significant
Some
WF10 Weather conditions HF10 Physical stress Some Significant
Significant

Congestion / restriction / Some

WF11 HF11 Mental stress Some Significant
access Significant
Some
WF12 Routine / non routine task HF12 Confidence level Some Significant
Significant
Some
WF13 Fire and/or explosion HF13 Secondary goals Some Significant
Significant
Some
WF14 Lighting HF14 Personal issues Some Significant
Significant

Equipment / material Some Distraction / pre-

WF15 HF15 Some Significant
temperature / conditions Significant occupation

Some Experience /
WF16 Noise HF16 knowledge / skill for Some Significant
Significant
task
Some
WF17 Ventilation HF17 Competency Some Significant
Significant
Some
WF18 Gas, dust or fumes HF18 Behavioral beliefs Some Significant
Significant
Some
WF19 Radiation HF19 Personality / attitude Some Significant
Significant
Some
WF20 Chemical HF20 Poor communications Some Significant
Significant

Some Poor shift patterns and

WF21 Wildlife HF21 Some Significant
Significant overtime working
Some Passive tolerance of
WF22 Surface gradient HF22 Some Significant
Significant violations

WF23 Other: HF23 Perceived license to Some Significant

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Workplace Factors Human Factors Impact

bend rules
HF24 Change of routine Some Significant

Reliance of
HF25 undocumented Some Significant
knowledge
HF26 Other
Code State details for the identified task/environmental factors that contributed to the
event

Organizational Factors
HW Supervision Contributing RM Risk Management Contributing

TR Training Contributing MC Management of change Contributing

OR Organization Contributing CM Contractor management Contributing

CO Communications Contributing OC Organizational Culture Contributing

IG Incompatible goals Contributing RI Regulatory Influence Contributing

PR Procedures Contributing OL Org. Learning Contributing

MM Maintenance management Contributing VM Vehicle management Contributing

DE Design Contributing MS Management systems Contributing

Code State details for the identified organisational factors that contributed to the event

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Appendix D – Notifiable Incident Definitions

WHS Notifiable incidents
An incident which involves:
• the death of a person
• a serious injury or illness of a person
• a dangerous incident.
When a notifiable incident occurs, the Manager, WHS will provide the appropriate
information in consultation with legal services to WHSQ immediately after becoming aware
that the incident has occurred at ‘Ezdihar AL-Garraf’. If the notifiable incident involves a
serious electrical incident or a dangerous electrical event then the ESO must also be notified
by the Manager, WHS.
The Manager, WHS will also immediately notify Seqwater’s Legal Services Manager for the
purpose of seeking legal counsel for the notifiable incident and gaining advice on all external
notifications and communication with regulators.
If a fatality occurs, the Manager, WHS or nominated representative will immediately
telephone the nearest office of WHSQ (or any Inspector) and the Queensland Police
Service to provide relevant information about the incident.

Dangerous electrical event

A dangerous electrical event includes:
• when a person, for any reason, is electrically unsafe around high voltage electrical
equipment, even if the person doesn’t receive an electric shock or injury
• significant property damage caused by electricity or something originating from
electricity e.g. electrical fire
• unlicensed electrical work
• unsafe electrical work
• unsafe electrical equipment or electrical equipment that does not have electrical
equipment safety system (EESS) approval markings.
Note: high voltage means a voltage above 1000 V AC or 1500 V ripple-free DC.

Dangerous incident
An incident in relation to a workplace that exposes a worker or any other person to a serious risk
to a person's health or safety emanating from an immediate or imminent exposure to:
• an uncontrolled escape, spillage or leakage of a substance
• an uncontrolled implosion, explosion or fire
• an uncontrolled escape of gas or steam
• an uncontrolled escape of a pressurized substance
• electric shock
• the fall or release from a height of any plant, substance or thing

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• the collapse, overturning, failure or malfunction of, or damage to, any plant that is
required to be authorised for use in accordance with the regulations
• the collapse or partial collapse of a structure
• the collapse or failure of an excavation or of any shoring supporting an excavation
• the inrush of water, mud or gas in workings, in an underground excavation or
tunnel
• the interruption of the main system of ventilation in an underground excavation
or tunnel.

Serious bodily incident

An injury or illness requiring the person to have:
• immediate treatment as an in-patient in a hospital
• immediate treatment for:
− the amputation of any part of his or her body
− a serious head injury
− a serious eye injury
− a serious burn
− the separation of his or her skin from an underlying tissue (such
as degloving or scalping)
− a spinal injury
− the loss of a bodily function
− serious lacerations
• medical treatment within 48 hours of exposure to a substance.

Serious electrical incident

An incident when a person:
• was killed by electricity
• received a shock or injury from electricity, and was treated for the shock or injury
by or under the supervision of a doctor
• received a shock or injury from electricity at high voltage, whether or not the person
was treated for the shock or injury by or under the supervision of a doctor.

Note: high voltage means a voltage above 1000 V AC or 1500 V ripple-free DC.

Environmental Breaches
Due to the complexity of environmental regulation the decision to notify environmental
regulators will be made by the SME Manager and SME Principal in consultation with
Legal Services where required.

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