INC Number Incident Reporting Form
(Use ball point pen only & complete in block letters
(electronic form in PJV Document Centre)
PART A: INITIAL REPORT (Information to be entered into IN-CONTROL within 24 hours)
Report Details
1. Event Category H&S Environmental Operational Security Community
Event Type Illness Air Emissions Release Near Miss OPS Intruder/Trespasser Interaction
Injury Cultural Resource Disturbance Production Loss Media Attention
(select one only Lighting Environmental Hazard Property Damage Public Complaint
Near Miss H&S Impacts to Wildlife Road Slips Stakeholder/NGO Action
Regulatory Violation Legislative Delay Schedule Delays
Liquid Release
Near Miss ENV
Noncompliance, Exceedance or Deviation
Other Environmental Events
Public Resistance
Regulatory Enforcement
Event Sub Type Work Related Procedural Deviation (H&S & Environment classification to be completed by Safety or Environment Department)
(select one only) Non-Work Related High Potential
Internal
2. Department Department : Section: Sub Section: Sub-sub Section:
where Incident
Occurred
3. Event Date / Date of Event (dd/mmm/yyyy) Time of Event (24hr clock) Date Reported Time Reported (24hr clock)
Time (dd/mmm/yyyy)
/ / / / / /
4. Event Reported Reported By: Pay Number:
Reported to: Pay Number:
5. Location Was Fatigue a Factor?
Yes No
Aviation Fires (Mobile Equipment) Mobile Equipment (Heavy Equipment)
Confine Space Ground Falls (Surface or Underground)) Mobile Equipment (Heavy Vehicle/Light Vehicle Interaction
6. Fatal Risks Cranes & Lifting Devices Handling Explosives & Blasting Operations (Failure or Collapse Infrastructure)
Electrical Hazardous Materials & Biological Agents Stored Energy
Fall from Heights Machine Guarding & Barricading Trenches & Excavation
Fires (Fixed Plant Mobile Equipment (Light Vehicles) N/A
[Link]/Incident
Title
8. Describe the Brief description of what happened, injuries or any equipment / environmental damage sustained, activity at the time
Event in Sufficient
Detail
(If the incident
involves
equipment/person.
Do complete tabs
# 11 & 12
required)
Immediate Action
Taken
Rev Document Number Reviewer Approver Issue Date Review Date Page
0 OHS-SIT-TEM-0007 Bowron, Mike Sheahan, Robin 7/04/2020 7/04/2023 1 of 4
Event Impacts Aggressive Interaction Intruder/Trespasser Sabotage Weather
(Were there any Cyanide Release Mercury Related Schedule Delays Wildlife and Habitat
secondary Enviro Legal & Other Requirements Natural Disaster Spill or Release N/A
impacts caused Fire/Explosion Production Loss Stakeholder/NGO Action
by the main H&S Regulatory violations Property Damage Theft
Illegal Mining Activity Road Slips Waste Management
incident?)
[Link]
Assessment Legend Low Medium High Very High/ Unacceptable
Actual Outcome Consequence
What actually 1 2 3 4 5 6 7
happened?
Most Certain (A) M28 M24 H19 VH13 UA4 UA2 UA1
(Place a circle
Likelihood
around the risk Likely (B) M29 M25 H20 VH15 UA7 UA5 UA3
rating that Possible (C) L32 M27 H22 H18 VH14 UA8 UA6
best
Unlikely (D) L34 L31 M26 H21 VH16 UA10 UA9
represents the
actual Very Rare (E) L35 L33 L30 H23 VH17 UA12 UA11
outcome of the
incident)
Potential
Consequence Legend Low Medium High Very High/ Unacceptable
What could have Consequence
happened?
1 2 3 4 5 6 7
(Place a circle
around the risk Most Certain (A) M28 M24 H19 VH13 UA4 UA2 UA1
rating that best Likely (B) M29 M25 H20 VH15 UA7 UA5 UA3
Likelihood
represents the
Possible (C) L32 M27 H22 H18 VH14 UA8 UA6
potential
consequence of Unlikely (D) L34 L31 M26 H21 VH16 UA10 UA9
the incident) Very Rare (E) L35 L33 L30 H23 VH17 UA12 UA11
Were People Involved? Complete the Participant Tab
11. Person #1* Surname: First Name: Employee Gender:(M/F)
Involved Contractor
Occupation/Job Title: Employer:
If Contractor, Company Name:
Start of Shift: (24hr clock): / Days into Rotation:
Incident Involvement Witness Team Member Supervisor Other (please describe)
11A. Person #2* Surname: First Name: Employee Gender:(M/F)
Involved Contractor
Occupation/Job Title: Department:
If Contractor, Company Name:
Start of Shift: (24hr clock) : Days into Rotation:
Incident Involvement Witness Team Member Supervisor Other (please describe)
11B. Person #3* Surname: First Name: Employee Gender:(M/F)
Involved Contractor
Occupation/Job Title: Department:
If Contractor, Company Name:
Start of Shift: (24hr clock) : Days into Rotation:
Incident Involvement Witness Team Member Supervisor Other (please describe)
Rev Document Number Reviewer Approver Issue Date Review Date Page
0 OHS-SIT-TEM-0007 Bowron, Mike Sheahan, Robin 7/04/2020 7/04/2023 2 of 4
Was Equipment Damaged? Complete the Equipment Tab
Class Item Class Item
Assay Lab Leach Conditioning Tank Agi Truck Loader Service Truck
Autoclave 1 Sag Mill 1 Crane OP Dump Truck UG Dump Truck
Diamond Drill Roller UG Loader
Autoclave 2 Sag Mill 2
Mobile Dozer Scissor Truck
Fixed Plant Autoclave 3 Sag Mill 3
Equipment - HV Excavator Shovel
Autoclave 4 Wash Thickener 1 Simba
Grader
Crusher Wash Thickener 2
Jumbo Surface Drill
ATV Ranger Lube Truck Air Leg & Machine Lathe
Backhoe Normet Battery Cable Cutter Lawn Mower
Chain Saw Pedestal Drill
Bobcat/Skid Steer Service Truck Powered Tools
Drill Rattle Gun
Mobile Buses Small Truck
Grinder Whipper Snipper
Equipment LV Explosive Truck Suck Truck
Hilti Drill
Fire Tender Tyre Handler
Forklift Washer Building and Infrastructure Other
IT Water Truck Other Fencing
Light Vehicle
Axe Pick Compressor Kerb Machine Sykes Pump
Bush Knife Rake Flight Pump Lighting Plant Took Carrier
Hand Shovel Scaling Bar Gantry Crane Man Lift Transformer
Non Powered Static & Mobile Welder
12. Was Hand Tools Generator Mono Pump
Tool Plant High Pressure Water Pioneer Pump
Equipment
Hoist Scissor Lift
Involved?
Complete the Asset No: Operator: Damaged Occurred
Equipment Tab (If ticked complete damage agency, location, mechanism and nature)
Damage Agency Damage Location Damage Mechanism Damage Nature
Animal/Insects Plant & Equipment On Site Caught in/on Repairable
Unrepairable
Asbestos/Fibres Poor Design/Not Fit for Purpose Off Site Collapse
Stolen/Lost
Biological Surface/Terrain Collision
Building/Structures Tools Contract/Exposure
Chemical/Radiation Training System Failure/Breakage
Human Wilful Act Fire/Explosion
Maintenance systems Other Water/Flooding
Other
Comments
Environmental Information
Impact Type Mechanism of Incident
Air Reputation Noise or vibration from blasting / plant operation Community complaint
Cultural / Heritage Noise Other environmental mechanism Culture / heritage site discovery or
Flora / Fauna Vibration Sediment capture, storage or discharge disturbance
Land Odour Site clearance Engineering / design
Public / Community Infrastructure Traffic management or movement Erosion by water or wind
Waste collection, storage or disposal Fire
Water Human Health
Chemical or hydrocarbon spill or leakage Material selection, Handling / Storage
Legal and other requirements
13. Was there an Receiving Medium Agency of Incident Volume of Agent Released Volume of Agent Recovered
Air Atmospheric Emission N/A N/A
Environmental
Ground Chemical/Hazardous Substances <1 Litre \ Kg Nil
Impact?
Waterway Human Interaction 1 – 5 Litres / Kgs <1 Litre \ Kg
Complete the 1 – 5 Litres / Kgs
Secondary containment Hydrocarbon 6 – 10 Litres / Kgs
Environmental Tab 6 – 10 Litres / Kgs
Noise 11 – 50 Litres / Kgs
Final Point of Impact? Process Water/Mine Contact Water 51 – 100 Litres / Kgs 11 – 50 Litres / Kgs
Yes No Radioactive Material 101 – 200 Litres / Kgs 51 – 100 Litres / Kgs
Vehicle 201 – 500 Litres / Kgs 101 – 200 Litres / Kgs
501 – 1000 Litres / Kgs 201 – 500 Litres / Kgs
> 1000 Litres / Kgs 501 – 1000 Litres / Kgs
> 1000 Litres / Kgs
Agent Volume (L) Volume (L)
Rev Document Number Reviewer Approver Issue Date Review Date Page
0 OHS-SIT-TEM-0007 Bowron, Mike Sheahan, Robin 7/04/2020 7/04/2023 3 of 4
Area of Impact Nature of Incident Duration of Incident Duration of Impact
Within immediate extent of incident Dust Nuisance Less than 1 day Hours Negligible (< 1 day) Hours
Within boundary of mine area Days Days
Energy Wastage 1 to 3 days Short Term (1 day to 1 month)
Weeks Weeks
Outside mine area Fauna Death 3 to 7 days Months Medium Term (1 month to 1 yr) Months
Within region Fauna Disturbance 1 to 2 weeks Years Long Term (> 1 year) Years
Global Heritage Site Disturbance 2 to 4 weeks Permanent
Land Contamination 4 + weeks
Area (M2) Noise Nuisance No of Units No of Units
Resource Wastage
Water Pollution
Remediation and Disposal
Comments
Species Impacted
Species Name: Protected: Number: Habitat
Yes No Bush River
Forest Woodland
Ocean
Documents
If you have photos or documents such as witness statement etc., please upload to Document tab
Signature Block
Individual Date:
Name: Signature:
Signature / /
Supervisor Date:
Name: Signature:
Signature / /
Rev Document Number Reviewer Approver Issue Date Review Date Page
0 OHS-SIT-TEM-0007 Bowron, Mike Sheahan, Robin 7/04/2020 7/04/2023 4 of 4
