As my Role as HSM at a MHF Site My reference is for MHF Sites, however the definitions remain unchanged for any Notifiable Incidents:
https://www.worksafe.govt.nz/notifications/notifiable-event/what-is-a-notifiable-event/
I have cut this from my Incident Reporting Document. I hope these help..feel free to use these in your improved Incident Forms:
WorkSafe Notifiable Incident Category: HSWA Section 24
☐(a) an escape, spillage or leakage of a Controlled Substance, (b) ☐ (an implosion) ☐ explosion ☐ fire
☐(c) an escape of gas, steam or ☐(d) an escape of pressurized substance ☐ (e) electric shock
☐ (f) the fall or release from a height of any plant, substance, or thing
☐ (g) the collapse, overturning, failure, or malfunction of, or damage to, any plant that is required to be authorized for use in accordance with regulations
☐ (h) the collapse or partial collapse of a structure ☐ (i) the collapse or failure of an excavation or any shoring supporting an excavation
☐ (j) the inrush of water, mud, or gas in workings in an underground excavation or tunnel
☐ (k) the interruption of the main system of ventilation in an underground excavation or tunnel
☐
(l) a collision between 2 vessels, a vessel capsize, or the inrush of water into a vessel; or
☐(m) any other incident declared by regulations to be a notifiable incident for the purposes of this section.
WorkSafe Notifiable Incident Category:
The following incidents arising out of, or in connection with, a major hazard facility are declared notifiable incidents under HSWA Section 24(1)(m) of the Act.
MHF Regulations 2016 Major Hazard Facility (MHF) Regulation 33 Incident:
Notified under HSWA Section 56 and MHF Regulations 2016 Major Hazard Facility (MHF): Regulation 33 & Regulation 34
Major Incident means an Uncontrolled Event at a Major Hazard Facility(MHF) that:
☐ (a) involves, or potentially involves, specified Hazardous Substances;
☐ (b) exposes multiple persons to a serious risk to their health or safety (including a risk of death) arising from an immediate or imminent exposure to: 1 or more of those substances as a result of the event; or the direct or indirect effects of the event.
Type of Declared Major Hazard facility(MHF)Regulation 33 – Notifiable Incident:
☐ (a) An unplanned event (other than a false alarm) that requires the Emergency Plan to be implemented
☐ (b) An event that does not cause, but has the potential to cause, a major incident
☐ (c) Damage to, or failure of, a Safety-Critical Element (SCE) that requires intervention to ensure it will operate as designed. e.g. Fire Sprinkler Activation
☐ (d) Unintended release of Hazardous Substances
Important: Notifiable Incident Major Hazard Facility Form: WKS-14 as PDF if you want to print:
and email to:
healthsafetydotnotificationatworksafedotgovtdotnz &
hhudotmhfatworksafedotgovtdotnz
Alternatively for any Notifiable Incident Capture Directly using Internet Form:
https://www.worksafe.govt.nz/notify-worksafe/
NB: Immediately Call & Record Date Incident WorkSafe: call: 0800 030 040:
Only use this form for initial notification of one of the incidents set out in Regulation 33 of the Regulations.
* The notification must include the information required under Schedule 4 of the Health and Safety at Work (Major Hazard Facilities)Regulations 2016 to the extent that it is reasonably available to the operator at the time of notification.
2305WKS-14-MHF-notifiable incident-form
Use this form WKS-14, for subsequent written reports required by the Health and Safety at Work (Major Hazard Facilities) Regulations 2016.
Serious Hazard Type Causing Injury: Harm and Risk rating must be factored into decision to classify Incident type. i.e. generally these "STOP6 Categories" could result in a Notifiable Incident
☐ Contact with Vehicle (Which Type?)
☐ Contact with Heavy Object (What Falling Load?)
☐ Caught or Pinched by machine/load
☐ Falling from Elevated Height (feet >2m from floor)
☐ Electric Shock
☐ Contact with Heated or Chemical Substance
WorkSafe Notifiable Injury Category: HSWA Section 23
☐ Fatality
☐ Loss of Bodily Function (Unconsciousness)
☐ Spinal Injury
☐ Serious Head Injury
☐ Amputation
☐ Serious Eye Injury
☐ Serious Burn
☐ Separation of skin(de-gloving / scalping)
☐ Serious Laceration(Major Loss of Blood - Artery)
☐ An Injury or illness that requires (or would usually require) a person to be admitted to a hospital for immediate treatment.
☐ An injury or illness that requires (or would usually require) a person to receive medical treatment within 48 hours of exposure to a substance.
Non Reportable WorkSafe Injury Type:
☐ Chemical Burn(Dermal)
☐ Chemical Eye Injury
☐ Chemical Inhalation
☐ Foreign Body In Eye(Dust)
☐ Bruise/Contusion
☐ Sprain(Ligament Tear)
☐ Strain(Muscle/Tendon Tear)
☐ Fracture
☐ Dislocation
☐ Minor Laceration(Minimal Loss of Blood-Veins)
☐ Abrasion / STI (Soft Tissue Injury)
☐ Crush
☐ Electric Shock
☐ Other(Specify):