Reviewing a Task Analysis after a near miss

A near miss is the cheapest information a site ever gets. Some near misses must be notified to WorkSafe as soon as possible, some require the scene to be left alone, and all of them are a reason to look again at the document that said the task was under control.

First: is it notifiable?

The Act defines a notifiable event in section 25 as a death, a notifiable injury or illness, or a notifiable incident. A near miss that hurt nobody can still be a notifiable incident.

Section 24 defines a notifiable incident as an unplanned or uncontrolled incident that exposes a person to a serious risk to their health or safety arising from immediate or imminent exposure to things including an escape or spillage of a substance, an uncontrolled implosion, explosion or fire, an escape of gas or steam or pressurised substance, electric shock, the fall or release from height of any plant, substance or thing, the collapse or partial collapse of a structure, the collapse or failure of an excavation or its shoring, the inrush of water, mud or gas in workings in an underground excavation or tunnel, and the interruption of the main system of ventilation in an underground excavation or tunnel.

If the event is on that list, section 56 requires the PCBU to notify WorkSafe as soon as possible after becoming aware of it. The duty does not wait for an investigation.

A scaffold plank falling to a walkway where nobody happened to be standing is a release from height that exposed people to serious risk. Nobody was hurt and it is still notifiable.

Second: do not disturb the site

Section 55 requires the PCBU that manages or controls the workplace to take all reasonable steps to make sure the site is not disturbed until an inspector authorises it. The exceptions are narrow: anything essential to make the site safe or to minimise the risk of a further notifiable event, anything done by or at the direction of the police, and anything an inspector or WorkSafe has given permission for. Helping an injured person is part of making the site safe; it is not a reason to tidy up.

Clearing up before taking photographs is the usual mistake. Photograph it first, from several angles, with something for scale.

Third: keep the record

Section 57 requires a PCBU to keep records of each notifiable event for at least five years. Beyond the statutory minimum, the useful record is the one that lets you reconstruct the day: what the task was, which version of the document was in use, who was briefed and when, what the conditions were, what actually happened and what changed as a result.

Reviewing the task document

The regulations require control measures to be maintained and reviewed, and an incident or near miss is one of the clearest triggers there is. The review is not about assigning blame; it is about finding which of four things went wrong.

1. The hazard was not in the document. Add it, and ask why the task breakdown missed it. Often the step it belonged to was written too broadly.
2. The hazard was there but the control was wrong. The control did not address the mechanism, or it sat too low in the hierarchy. Work back up regulation 6.
3. The control was right and was not in place. Then the question is why. No equipment, no time, no one responsible, or a crew who did not know. Each has a different fix, and "remind the team" is rarely the right one.
4. The control was in place and was not enough. This most often means the residual rating was optimistic.

What a good revision looks like

• The change is specific. A new step, a named control, a different sequence.
• The residual rating moves, or the document says why it did not.
• The revision is dated and the version is identifiable, so the copy at the work face can be told from the one in the folder.
• The crew is re-briefed and signs on again. A revised document nobody has been told about is a worse position than the original, because the record now says they were briefed on something they were not.
• If the same gap could exist in your other task documents, they get looked at too. This is the step that turns one near miss into a real improvement.

Near misses that are not notifiable

Most are not, and they are still worth capturing. A simple log with the date, what happened, which task it was and what changed is enough. The toolbox talk is the natural place to raise one, and discussing a real event from this site beats any general topic.

The pattern to watch for is repetition. The same near miss recurring is a control that is not working, regardless of what the document says about it.

Sources

• Health and Safety at Work Act 2015, ss23 to 25 (notifiable injury or illness, notifiable incident, notifiable event), s55 (preservation of sites), s56 (duty to notify), s57 (duty to keep records)
• Health and Safety at Work (General Risk and Workplace Management) Regulations 2016, reg 6 and reg 8 (review of control measures)
• WorkSafe New Zealand, Notifiable events, guidance on what and how to notify
• Health and Safety at Work Act 2015, ss58 to 59 and s61 (worker engagement and participation)

This guide is general information about New Zealand health and safety law as at the review date. It is not legal advice and it does not describe your site. Confirm what applies to you with WorkSafe New Zealand or your adviser.