Incident reporting and learning
All incidents, including near misses, must be recorded and analysed. Some must also be reported externally.
It is vital to ensure that learning is shared with your team and, where necessary, used to update your safety system.
What to report
To help create good safety reporting in your operation, your team needs to be very clear on what they should report i.e. there should be clear reporting triggers. This needs to include all incidents, those that could have (near misses) or did result in injury or illness, and should also cover any safety observations that could improve your safety systems.
Check the number of incidents being reported - a strong safety culture will include regular incident reporting including near misses . Nil or low reporting usually means there is a problem with your reporting culture, not that there are no incidents or concerns.
Some serious incidents are called notifiable events and need to be reported to a regulator - the regulator is either WorkSafe NZ, Maritime NZ or the Civil Aviation Authority.
Notifiable events include close calls that could have resulted in a death or notifiable illness or injury.
There are specific criteria for notifiable events including requirements not to disturb the site where the event has occurred until authorised by an inspector, and advice on when it is ok to do so to ensure people's safety. For more information see the WorkSafe NZ website.
All notifiable events related to the work being undertaken must be reported, this includes incidents involving participants. The same events are not notifiable if they are unrelated to the work being undertaken e.g. injuries triggered by a medical reason such as a fall due to a stroke.
If in doubt about whether an event is notifiable, discuss this with WorkSafe NZ as soon as possible.
Reporting incidents to your audit provider
Operators that come under the Adventure Activities Regulations are also required to report serious incidents to their audit provider. Talk with your audit provider and make sure you are clear on what they expect you to report.
"I want to prevent incidents and that means learning from near misses – there’s nothing worse than hearing after an incident that some or all of our team ‘saw that one coming'."
How to report
To encourage reporting avoid penalising people for reporting incidents - good reporting should be seen as positive behavior separate to whatever faults may have led to the incident itself.
Your reporting system should include:
- simple processes that encourage people to report and a culture where everyone feels safe in reporting things that aren’t right
- standardised reporting forms. Although most operators use one form for all, you may choose to use different forms/methods for different incident severities
- clear responsibilities e.g. who files the report, who receives it and who follows up on it
- timeframes for when a report must be filed after an incident
- criteria, timeframes and procedures for when a report must also be made to an external agency, e.g. WorkSafe NZ, Maritime NZ, Civil Aviation Authority - for a notifiable event this must be as soon as reasonably possible after becoming aware that the incident has occurred.
Consider engaging with your local WorkSafe Inspector and familiarise them with your operation. If you do have an incident, they will be in a better position to provide useful advice and support.
Learning and following up
Every incident is an opportunity to learn. To maximise this, it's important that all incidents (including near misses) are reported.
Analyse incident reports to find the actual and/or potential cause(s). Where necessary, each of these must have a follow-up action to stop it happening again.
Schedule regular incident reviews to look for trends. This can give you valuable insight which could otherwise be missed. If possible, connect with other operators to share learning.
"When we set up our reporting system, no one used it. A whole lot of things have eventually made it work – simplicity, training, persistence – but possibly the most important has been our commitment to follow-up on each report. Even now though, we need to keep pushing and leading by example to keep the reports coming in."
The records of your incident management processes are important for you and for any external checks.
- copies of all completed incident report forms and your accident register if you choose to use one
- minutes from incident review discussions, including participants’ names
- action and learning points resulting from incident reviews, and details on when and how they were followed up
- keep records of notifiable events for at least 5 years from the date on which the regulator was notified.