Safety Flashes are intended to summarise key safety matters and incidents, allowing wider dissemination of lessons learnt from them. The effectiveness of the safety flash system depends on receiving reports from members in order to pass on information and avoid repeat incidents.

The information provided in this template is reviewed by the Marlborough Safety Forum. An anonymised and sanitised version will be prepared for your acceptance once authorised it will be emailed to the Marlborough Safety Forum distribution list and uploaded to http://www.marlboroughsafetyforum.com/.

If possible, please include photographs or diagrams with some explanatory text.

Please send the finished submission to marlborough.safety@gmail.com

Contact details for final approval: Name: Email:
Title:	A concise focus on the main issue, capturing the essence of the incident – e.g. “fatality during harvest operations”

What happened?	Brief description of what happened, roughly between 50-200 words, or more for complex cases. Names, locations and dates can be omitted, though this will checked carefully by the Board. If possible, try to outline the incident in the first sentence, before providing more detail thereafter: e.g. “A crew member was struck by a falling object. The incident occurred when…” If there were injuries, fatalities or other consequences like equipment damage or lost time, please tell us briefly what they were, and what treatment was required for the injured person(s). Please indicate if the incident was a near miss, an LTI, a Restricted Work case or a First Aid injury.

What went wrong? - Investigation and findings	All incidents should be investigated, all investigations have findings. Information you put in the “What happened” section may be moved to this section – for example, weather, or the experience and competence of the team involved. Typical findings include whether or not safety management tools such as risk assessment, toolbox talks, management of change etc. were properly used, or details of what actually went wrong, A real example is: “the installed winch was not suitable as it had no safety mechanism to prevent free fall when lowering”.

What were the causes of the incident	Identify the immediate causes, and as far as possible, the root causes, of the incident.

What lessons were learnt?	What were the main lessons learnt from the incident? What lessons could be applicable to the wider Wine Marlborough membership and the industry? How do we prevent recurrence of the incident?

Actions	What did changes did you make as a result of this incident? What actions, if any, can Wine Marlborough members take from this incident?