INCIDENT REPORTING AND INVESTIGATION

PROCEDURE

Document No: PGM HSE PRO 14 001B

Revision: A B

M Matthews/
Prepared by: W Astill
J Bromley/ C
Ellam/ B Morrow/ N
Reviewed by: B Sowden Taylor/ S Bidois

Approved by: J Bromley/S Bidois C McAuley

T Moylan C Winn

SUMMARY OF DOCUMENT REVISIONS

Rev. Date
Section
No. Revised Revised Revision Description

1 20/11/2012 All Yearly review: clarified environmental incidents; included

investigation requirement matrix, improved cross referencing.

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 TABLE OF CONTENTS

1. PURPOSE 3

2. SCOPE 3

3. DEFINITIONS AND ACRONYMS 3

3.1 Definitions 3

4. ROLES AND RESPONSIBILITIES 6

All Personnel 6
Area Supervisor 6
Line Manager 6
Health, Safety and Environment Manager 7
Health, Safety and Environment Superintendent 7
General Manager 7

5. TRAINING 7

6. PROCEDURE 7
6.1 Immediate Action and Reporting 7
6.2 Investigation Level Determination 8
6.3 Collection of Information 8
6.4 Investigation 9
6.5 Corrective Actions 9
6.6 Communication of Lessons Learnt 9

7. RECORD KEEPING 9

8. REVIEW 10

9. LEGISLATION AND STANDARDS 10

10. RELEVANT DOCUMENTATION 10

11. APPENDICES 10
APPENDIX A 11
Paddington Operations Risk Ranking Matrix 11
APPENDIX B 13
Investigation/Injury Reporting and Investigation Matrix 13
APPENDIX C 15
Medical Treatment Examples 15
APPENDIX D 17
5 Whys Analysis Form 17

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1. PURPOSE
This document sets out the requirements for effective reporting and investigation of
incidents and hazards occurring at Norton Gold Fields (NGF) Paddington Operations.
It is important that consistent, quality information is obtained about incidents and
their causes, to develop appropriate corrective actions to prevent their recurrence.
2. SCOPE
This Procedure applies to all sites within the NGF Paddington Operations.

3. DEFINITIONS AND ACRONYMS

3.1 Definitions
Incident Classifications

Hazard
A hazard is anything which has the potential to cause harm (ill health, injury or
damage to plant, property, the environment or community assets).

Incident
An incident is an unplanned or unwanted event that has or could have resulted in
harm.

Near Miss
A near miss is an incident that has not resulted in harm - that is there were no
consequences from the incident. However, under slightly different circumstances
there could have been.

Serious Potential Incident

A Serious Potential Incident (SPI) is any:

Incident where the potential consequences have been risk ranked as

Catastrophic, regardless of the actual consequences of the incident.
Incidents in which actual injury/illness, property loss/damage or environmental
damage has occurred as well as incidents which are near misses may be
classified as SPIs.
NB. Estimation of potential severity must be realistic and should consider the
outcome of the incident under slightly different circumstances.

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Reportable Incident
A Reportable incident is an occurrence required to be reported to the District
Inspector of Mines as set out in:
Section 78 of the Western Australian Mines Safety and Inspection Act 1994;
the Mining Act 1978 via tenement conditions;
or to the Department of Environment and Conservation:
the Environmental Protection Act 1986 (Section 72);or
the Contaminated Sites Act 2003 if an incident creates a suspected or known
contaminated site.

Reporting of damage to community assets (cultural heritage) can be required under

the Aboriginal Heritage Act 1972.
There are other Acts relating to incidents that may need to be considered on a case
by case basis for unique incident types.

Injury Classifications

Work Related Fatality

A work related fatality is a death resulting from a work related injury or illness.

Lost Time Injury (LTI)

A Lost Time Injury is any work-related injury that results in the injured person being
absent from work, as a direct result of the severity and nature of the injury, for one full
shift or longer. Shifts lost as a direct consequence of the time taken to obtain a
confirmation on diagnosis or treatment do not cause an injury to be classified as a
Lost Time Injury (e.g. due to remote location).

Modified Work Injury (MWI)

A Modified Work Injury is a work-related injury or illness, where a doctor or other
licensed health care professional considers it necessary to keep the employee from
performing one or more of the routine functions of their job or from working a full shift.

Medical Treatment Injury (MTI)

A Medical Treatment Injury (MTI) is any work-related injury that:
is outside the scope and capability of a first aider
requires treatment by, or under the specific order of a medical practitioner or
any injury that could be considered as being one that would normally be
treated by a medical practitioner; and
is not a lost time injury or a modified work injury
In simple terms, an MTI is more serious than a First Aid Injury, but less serious (as
determined by the degree of incapacitation or in terms of time lost) than an LTI or
MWI.
Examples of MTIs are contained in Appendix C.

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First Aid Injury (FAI)
A First Aid Injury is any work-related injury/illness that is managed by first-aid
treatment only, regardless of who administers the first aid treatment.

Disabling Injury
This is a statutory classification that applies only in WA. (Reference: WA DMPR
Guideline: Occurrence, Accident and Occupational Disease Legislative Reporting
Requirements, May 2001)
An injury that results in the injured person being disabled so that they are unable to
return to their ordinary occupation the following day, regardless of whether the
person is rostered to work the following day or not. This includes disabled persons
assigned to alternate duties

Total Recordable Injury (TRI)

Total Recordable Injuries (TRIs) is an indicator developed by the minerals industry and
includes all injuries except first aid cases. This includes lost time injuries, medically
treated injuries and modified work Injuries

Routine Functions
Routine functions are those work activities the employee usually performs at least
once per week.

Work Related Injury

An injury or illness is work related if an event or an exposure in the work environment
either caused or contributed to the resulting condition or significantly aggravated a
pre-existing injury or illness. Injuries and illnesses resulting from events or exposures
occurring in the work environment are presumed to be work related, unless listed in
the exceptions described below:
Exceptions for where injuries are not considered work related
An injury or illness occurring in the work environment that falls under one of the
following exceptions is not work related
The injury or illness involves signs or symptoms that surface at work but result
solely from a non-work related event or exposure that occurs outside the work
environment
The injury or illness results solely from voluntary participation in a wellness
program, a medical, fitness, sporting or recreational activity.
The injury or illness is solely the result of an employee eating, drinking or
preparing food or drink for personal consumption
The injury or illness is solely the result of an employee doing personal tasks
(unrelated to their employment) at the establishment outside the employees
assigned working hours
The injury or illness is caused by a motor vehicle incident and occurs in a
company car park or company access road while the employee is
commuting to or from work
The injury or illness occurs whilst the employee is at a home away from
home, e.g. a hotel, motel or other temporary residence, even though they
are there in the course of their work
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 The illness is the common cold or flu. (Note: contagious diseases such as
infective gastroenteritis, brucellosis, hepatitis A, tuberculosis are considered
work-related if the employee is infected at work).

Environmental Incident Classifications

Level 1 Incident
A Level 1 incident is one that results in negligible damage to the environment or
heritage feature.
Level 2 Incident
A Level 2 incident is any other environmental incident including causing minor, short-
term or long-term damage.

4. ROLES AND RESPONSIBILITIES

All Personnel
Report any incidents or near misses that they have observed or been involved
in to their supervisor.
- Make the area safe.
- If required, seek first aid attention for either self or person(s) involved in
event.
- Isolate the area if required.
- Ensure that the area involved with an incident is not disturbed.

Area Supervisor
Make preliminary assessment of incident and preserve conditions where
practicable.
In conjunction with the person/s involved enter the incident information into
STEMS.
Assess/determine incident classification as defined above in Section 3.
Determine level of investigation in conjunction with Line Manager.
Report incidents to senior personnel in accordance with the Incident/Injury
Reporting and Investigation Matrix.
Prepare or assist in preparation of incident reports to external authorities in the
format required by the relevant Act(s).

Line Manager
Liaise with supervisor to assess incident classification
Notify relevant parties (internal/external)
Confirm the level of investigation (using Incident/Injury Reporting and
Investigation Matrix.
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 If deemed necessary based on the risk ranking of the incident, appoint an
ICAM investigation team.
Review investigation report findings and recommendations.

Health, Safety and Environment Superintendent

Participate in the investigation process as required.
Ensure that information is collected and presented to the investigation team
where an ICAM is the required investigation method.
Prepare or assist in the preparation of reports to external authorities in the
formats required by the relevant Acts.

Health, Safety and Environment Manager

Ensure this procedure is implemented at all sites under the control of NGF
Paddington Operations.
Monitor the extent and level of investigation to ensure it is consistent with the
Risk Ranking Matrix and recommend any upgrade or down grade of level.
Participate in the investigation process as required.
Monitor the database to ensure that the corrective actions have been
implemented by their due date.
Review the quality of reporting and investigations and make
recommendations to management as required.
Ensure that a sufficient number of key employees are trained in the
application of the ICAM investigation process.
Responsible for periodic review of this Procedure.

General Manager
Responsible for ensuring sufficient resources are available to implement this
Procedure.
Responsible for signing off incident reports to external authorities.
5. TRAINING
All personnel shall be informed of their responsibilities regarding the reporting and
investigation of incidents and near misses during the General Site Induction.
Those personnel required to facilitate ICAM investigations shall undergo ICAM
training.

6. PROCEDURE

6.1 Immediate Action and Reporting

When an incident occurs, immediate action is required to prevent escalation and
further injury/damage. In the case of injury the first action involves treatment and
assessment by an appropriately trained first aider.
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Where possible the site should be left undisturbed until the investigation team has
inspected it. Where this is not possible, photographs should be taken or sketches
made of the scene.
The Area Supervisor must be advised of the incident and an assessment of the
problem should be made to identify the extent of injury and/or damage.
All incidents shall be notified immediately to the Line Manager, HSE Manager
and Mine Manager in accordance with the NGF Paddington Operations
Incident/Injury Reporting and Investigation Matrix.
Notification should contain details of:
Time, place and nature of the incident
Persons injured, equipment damage
Nature of injury/damage and estimate of severity
Immediate corrective action being taken
Activity in progress at the time

6.2 Investigation Level Determination

The Area Supervisor determines the level of investigation based on the classification
of the incident.
The HSE Manager may recommend to Management upgrade or downgrade of the
level after consideration of all circumstances associated with the incident.
The level of investigation shall be based on a risk assessment of the incident with the
risk determined by consideration of the worst-case realistic scenario (potential
consequence).
The Risk Ranking Matrix shall determine the level of investigation required. The level
of investigation can range from:
Direct entry into STEMS
Written Report (5 Whys)
ICAM Investigation
The Investigation shall be conducted in accordance with the training provided for
each level of investigation.

6.3 Collection of Information

The facilitator of the investigation shall, where required, request the HSE
Superintendent to collect information required for the investigation and present it to
the investigation team.
The HSE Superintendent shall ensure that in the event of an ICAM being required, all
relevant information pertaining to the incident is collected, collated and presented
to the investigation team in a clear and concise manner.

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6.4 Investigation
An investigation is to:
Document and describe the incident or near miss in detail,
Establish the contributing factors and root causes leading to it; and
Identify the corrective actions required to eliminate or prevent a recurrence.
The timing of the investigation shall be dependent on completion of the collection of
information and the nature of the incident. The investigation shall be scheduled by
the facilitator.
The personnel required to participate in investigations and the type of investigation
shall depend on the risk ranking of the incident. The investigation requirements matrix
shall provide guidance on the type of investigation required and the personnel who
should participate in the investigation process.
Upon completion of the investigation, documentation shall be forwarded to the HSE
Superintendent for entry into STEMS.

6.5 Corrective Actions

The principal objective of an investigation is to take action to prevent further
incidents of this kind. There should be at least one recommendation addressed to
each identified cause. Recommendations should be:
S Specific
M Measurable
A Accountable
R Reasonable
T - Timely
E - Effective
R Reviewed
Corrective actions shall be entered into STEMS and tracked to completion.

6.6 Communication of Lessons Learnt

The lessons learnt must be communicated to the wider organisation so that all
employees can benefit from an investigation. After the investigation and findings are
reported, the relevant line manager will send the incident investigation details to the
HSE Superintendent. The HSE Superintendent, in consultation with the Line Manager,
will prepare and distribute an Incident Alert.
A short presentation about the investigation and its findings and recommendations
should be given to the workforce.

7. RECORD KEEPING
Incident reports, Incident Alerts and ICAM investigation reports are retained on
STEMS.

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8. REVIEW
A review shall be carried out to ensure the content of this procedure is still
applicable, current and practicable. A review should take place:
a. Whenever the process/equipment changes
b. At a periodic frequency (every two years)
c. At incident investigation.

9. LEGISLATION AND STANDARDS

Mines Safety and Inspection Act
Mines Safety and Inspection Regulations
Australian Standard As 1885.1 1989 Recording and Measuring Work Injury
Mining Act 1978
Environmental Protection Act 1986 (Section 72)
Contaminated Sites Act 2003
Aboriginal Heritage Act 1972

10. RELEVANT DOCUMENTATION

The following documentation may be utilised or referenced to comply with the
requirements of this procedure:
Paddington Gold 5 Whys Analysis Form
ICAM Incident Investigation Reference Guide

11. APPENDICES
Appendix A Paddington Gold Risk Ranking Matrix
Appendix B Incident/Injury Reporting and Investigation Matrix
Appendix C Medical Treatment Examples
Appendix D 5 Whys Analysis Form (Word version on STEMS PGM-HSE-
FRM-14-001)

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 Appendix A

PADDINGTON OPERATIONS
RISK RANKING MATRIX

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Combine the results from Table A and B to calculate the risk ranking on Table C
TABLE A. CONSEQUENCE OF EVENT (Actual and Potential)
Level Descriptor Injuries Environment Corporate liability Cost
1 Insignificant Minor No permanent damage to the No corporate liability <$10,000
injuries environment or heritage feature
2 Minor First aid Spillage immediately contained; Low corporate $10,000 - $50,000
treatment Minor short-term damage to the liability
environment or heritage feature;
3 Moderate Minor Spillage contained with some Moderate level of $50,000 -
medical difficulty; corporate liability $750,000
treatment Significant short-term or minor
long-term damage to the
environment or heritage feature.
4 Major Serious Major short-term or significant long- High level of $750,000 -
extensive term damage to the environment or corporate liability. $3,000,000
injuries heritage feature.
5 Catastrophic Fatality Major long-term damage to the Very high level of >$3,000,000
environment or heritage feature corporate liability
TABLE B. LIKELIHOOD OF EVENT OCCURRING
Level Descriptor Description
A Almost Certain Is expected to occur in most circumstances (ie > once per day)
B Likely Will probably occur in most circumstances (ie > once per month but < once per day)
C Possible Should occur at some time (ie > once per year but < once per month)
D Unlikely Could occur at some time (ie < once per year)
E Rare May occur only in exceptional circumstances (ie unlikely to ever occur)

TABLE C. RISK RANKING

Consequences
Likelihood 1 2 3 4 5
A 15 10 6 3 1
B 19 14 9 5 2
C 22 18 13 8 4
D 24 21 17 12 7
E 25 23 20 16 11

RISK LEVEL
TYPE RANKING ACTION
Extreme risk 15 Cease all affected work immediately.
In the event of an incident an
ICAM is required.
Immediate action required.
High risk 9 12 Consider ceasing all affected work.
In the event of an incident an ICAM is to be considered.
Action/s & responsibilities to be assigned by end of the
shift.

Moderate risk 13 19 In the event of an incident an ICAM is to be considered.

Manage by routine procedures.

Low risk 20 25 Manage by routine procedures.

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 Appendix B

INVESTIGATION/INJURY
REPORTING AND
INVESTIGATION MATRIX

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 Incident/Injury Reporting and Investigation Matrix

Investigation Level
Injury/Incident Classification
Basic Shift Safety
ICAM Superintendent Dept HSE Superintendent/ General Managing
5 - Whys Supervisor Coordinator
Manager Manager Manager Director

*An Injury where immediate medical treatment is required I I I I NC NC

IMMEDIATELY
First Aid Yes No NC NC NC NC NC NC
Medical Treatment Injury Yes D I NC I I NC NC
Modified Work Injury Yes D I NC I I NC NC
Lost Time Injury Yes D I I I I NC NC
Fatality No Yes I I I I I I
Serious Potential Incident No Yes I I I I NC NC
Reportable Incident Yes D I I I I NC NC
Environmental Incident Level 1 Yes No NC NC NC NC NC NC
Environmental Incident Level 2 No Yes I I NC I NC NC

Notes
I = Immediately - means as soon as practicable after the incident has occurred - no matter what time of day or night. Priority shall be given to stabilising the injured and rendering the scene safe.
NC = Normal Communication during business hours. Incident is to be reported upward verbally during normal business hours and entered into STEMS by the end of shift.
D = Department Manager's Discretion - At the very least the incident is to be investigated by the Supervisor/Superintendent. Using the 5 Whys method is preferable. It is at the Department Manager's
discretion whether an ICAM is to be carried out.
* This refers to an injury where, in the opinion of the Supervisor/Superintendent on advice of trained first aider, the injured person needs immediate medical assessment or treatment beyond what can be
provided by a trained first aider.

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 Appendix C

MEDICAL TREATMENT EXAMPLES

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 A Medical Treatment Injury Does include:
Use of prescription medications (except a single dose administered on the first visit for minor injury or discomfort)
Use of sutures or staples to close a wound
Treatment of partial or full thickness burns.
Removal of embedded objects or corrosive chemicals from eyes by medical staff
Injuries which result in loss of consciousness
Surgical debridement (removal of burned or damaged tissue)
Removal of foreign bodies from a wound if the procedure is complicated by the depth of embedment, size or location (does not include
the removal of small splinters).
Treatment of bruises by drainage
Treatment of extensive abrasions at greater than full skin depth
Series (more than two occasions) of physiotherapy or chiropractic treatment under the direction of a medical practitioner.
Admission to hospital or equivalent for observation after head injury, injury to chest or abdomen or inhalation of gases or fumes. Note:
the admission has to be based on severity of incident and/or symptoms, not on a hospitals automatic admission protocols.
Use of non-prescription medication at prescription-equivalent dose/strength.
Any fracture
ECG after electric shock that shows abnormal rhythm of the heartbeat.

These treatments are considered to be Medical Treatments regardless of the professional status of the person providing the treatment.

The following Does Not constitute a Medical Treatment Injury:

Diagnostic procedures such as X-rays (unless the result is positive), ECGs (see above), laboratory analysis, blood tests,
administration of prescription medication used for diagnostic purposes, e.g. eye drops to dilate pupils unless they lead to further
medical treatment.
Tetanus shots or boosters.
Visit to a doctor solely for observation, counselling or confirmation of diagnosis without any further medical treatment or treatment that
could have otherwise been provided by a trained first aider.

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 Appendix D

5 WHYS ANALYSIS FORM

(Word version on STEMS PGM-HSE-FRM-14-001)

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 5 WHYS ANALYSIS FORM
STEMS Incident Number: Incident Location:

Incident date: Type of Process: Type of Equipment:

Team Members:

Incident Description:

FIVE WHYs
1. Why did the incident happen? What caused it? Verification /Reason

2. Why did 1 happen? Dig deeper

a)
b)
c)

3. Why did 2 happen? Dig deeper

a)
b)
c)

4. Why did 3 happen?

a)
b)
c)

5. Why did 4 happen?

a)

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Identify the Causes of the incident:
Description of Root Cause: Root Cause Categories:

Action Items:
Corrective Action to Control Causes Assigned to Target Date
Actions
1.

Specific 2.
Measurable
Actionable 3.
Relevant
Timely 4.

5.

6.

7.

8.

Investigation Sign Off

Name Signature Date

Facilitator
Name Signature Date

Supervisor
Name Signature Date

Superintendent
Name Signature Date
Department
Manager

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