GU-612 - Guidelines - Incident Investigation and Reporting (3)

Petroleum Development Oman L.L.C.

[Health Safety Environment & SD]

“Incident Investigation, Analysis and Reporting”

Guideline

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RESTRICTED Document ID: GU-612Apr-23 Filing Key: Business Control

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HSE – PROCEDURE

Embedding HSE into our Business

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HSE – PROCEDURE


i Document AuthorisationAuthorised For Issue

Document Authorisation

Document Authority

(CFDH)

Document Custodian Document Controller

NAAMAN NAAMANY

MSEM

Date: 30/08/2008

NIVEDITA RAM

MSE5

Date: 30/08/2008

NIVEDITA RAM

MSE5

Date: 30/08/2008

HSE – PROCEDURE


ii Revision History

Authorised for Issue by the HSE IC

Document Authorisation

Document Authority Document Custodian Document Author

Naaman Namany

Ref. Ind::MSEM

Date: 30/08/2008

Nivedita Ram

Ref. Ind::MSE/5

Date: 30/08/2008

Nivedita Ram

Ref. Ind: MSE/5

Date: 30/08/2008

The following is a brief summary of the seven most recent revisions to this document. Details of all revisions prior to these are held on file by the Document Custodian.

Version No. Date Author Scope / Remarks

Version2.0 August 08 Nivedita Ram

MSE5

Updated in line with the Yellow Guide – issue Dec 31, 2007. Inclusion of Incident Investigation Guidelines, ToR for MDIRC, OSHA Guidelines. The Guideline replaces the PR1418 Part II and Part III

Version 1.0 Dec-03 Ohimai Aikhoje

MSEM/4

Updated in line with new SIEP Standard for Health, Safety and Environmental Management Systems – Incident reporting and Follow up EP 2005-0100-29.

Follows new EP global procedure for Incident Reporting and Follow Up.

Version 1.0 July-03 Andrew Ure

MSEM/4X

Update Procedure to bring it into line with FIM Incident Management tool, and with PDO re-organisation (Version Not Issued)

Version 1.0 July-02 Chidozie Nzeukwu

MSEM/13

Supersedes HSE/97/01, Rev.3. Ratification of reportable incidents by Area HSE Team Leader initially instead of MSEM; update Environmental Incident Notification Form; include MDC review of contractor disqualification for fatal incidents per Commercial Procedures and Guidelines; add MD Review of Incidents meeting; clarify procedures relating to non-accidental death; align risk matrix with CP 122 HSE Management System Manual. Inclusion of information on PDO’s ‘incident tracking tool’. Inclusion of Guidelines on operation of IRCs.(Version Not Issued)

HSE/97/01, Rev.3

Apr-98 John Sherban, MSEM/5

Aligned with asset Management organisation

HSE/97/01, Rev.2

Feb-98 John Sherban, MSEM/5

Second printing with revisions

HSE/97/01, Rev.1

Jun-97 John Sherban, MSEM/5

Supersedes SRD/P/01, Rev.2. Reflects changes in PDO’s organisation structure and HSE-MS.

HSE – PROCEDURE


iii Related Business Processes

Code Business Process (EPBM 4.0)

iv Related Corporate Management Frame Work (CMF) Documents

The related CMF Documents can be retrieved from the Corporate Business Control Documentation Register TAXI.

http://sww1.pdo.shell.om/dept_applications/Infrastucture/IMandT/TAXI/cmf/index.htm

HSE – PROCEDURE


Contents

i Document Authorisation........................................................................................................................... 3

ii Revision History....................................................................................................................................... 4

iii Related Business Processes....................................................................................................................5

iv Related Corporate Management Frame Work (CMF) Documents.............................................................5

1..................................................................................................................................................................... 7

1. Incident Investigation & Analysis........................................................................................................9

1.1 Introduction...................................................................................................................................... 9

1.2 The Initial Investigation (immediate)...............................................................................................9

1.3 The Full Investigation....................................................................................................................10

1.4 Incident Reports............................................................................................................................. 20

1.5 Implementation of Recommendations..........................................................................................20

2: Ownership of Incidents.................................................................................................................20

3: Organization and ToR for PDO Incident Review Committees......................................................24

3.1 MD Incident Review Panel (MDIR)................................................................................................24

3.2 Directorate Incident Review Committees (IRCs)...........................................................................26

4: Definitions and Explanation of Terms..........................................................................................28

5: INCIDENT REPORT TEMPLATES..................................................................................................36

Appendix 1: High Potential Incident Reports...................................................................................36

Appendix 2: Non-accidental Death Reports......................................................................................38

Appendix 3: General Medium Potential Incident Report..................................................................39

Appendix 4: Medium Potential Road Traffic Accident Report.........................................................48

Appendix 5: List of Activity at time of Incident................................................................................59

Appendix 6: Definitions of Incident Types.......................................................................................61

Appendix 7: List of Immediate Causes.............................................................................................62

Appendix 8: List of Underlying Causes............................................................................................63

Appendix 9: List of Facilities / Plant / Equipment...........................................................................64

Appendix 10: List of Injury / Occupational Illness.............................................................................65

Appendix 11: Examples Determining Environmental Incident Risk Potential.................................68

1. Incident Investigation & Analysis

1.1 Introduction

The purpose of conducting an Incident investigation and producing a formal report on

the findings is:

To identify the direct, contributing and root cause(s) of an Incident To prescribe and implement suitable actions to prevent recurrence of a similar Incident To ensure that legal, PDO's and shareholder requirements on injury and Incident reporting

are met To protect against future unsubstantiated claims.

The Incident investigation, reporting and follow-up process comprises a number of consecutive stages once the initial PDO Notification procedure has been completed. These stages are:

Initial investigation / information preservation Formation of a full investigation team The full investigation Analysis of findings Preparation, review and publication of the report (including recommendations for remedial

action) Implementation of action items Follow-up to ensure remedial actions are completed.

Brief guidance is provided below on how to conduct an initial and full Incident investigation and how to complete the follow-up requirements.

1.2 The Initial Investigation (immediate)

The Responsible Supervisor/ Investigation Team Leader responsible for staff or equipment involved in the Incident shall immediately take steps to preserve the site as it is immediately after the Incident and if this is not possible to make notes, take photographs or draw sketches of all relevant details.

The objectives of the initial investigation and site preservation are:

a) To ensure that the site is made safe and that action has been taken to identify the most obvious cause(s) of the Incident and protect against recurrence.

b) To collect and preserve initial information prior to the site being disturbed. This will normally include:

Identification of witnesses, Documentation/procedures in operation at the time of the Incident, Phase of operations, process condition, etc., Markings left by equipment involved, Position of personnel and equipment, Documentation of Emergency Response procedures immediately following the

Incident, Time of day, Prevalent weather conditions.

Every opportunity should be taken to obtain photographs, statements, etc. during the initial investigation. Documentation such as 'Permits to Work' should also be collected and passed to the Investigation Team Leader.

Prior Planning includes the inclusion of the following

a) First Aid Kit

b) Camera

c) Journey plan

d) Fuel

Petroleum Development Oman LLC Revision: 2Effective: Sept ‘08

e) Accommodation

f) Water

g) Charger

1.3 The Full Investigation

1.3.1 Determination of Investigation Level and Team Composition

Following the initial investigation, by the Responsible Supervisor, the full investigation team shall be formed. The level of investigation, reporting and team composition required for a given Incident is determined by the Potential Risk of the Incident. The Incident owner is encouraged to lead the investigation in order to demonstrate an appropriate degree of commitment.

Suggested team composition for each level of risk is included in the following table. Additionally, if specific expertise is required to adequately determine the root causes leading to the Incident, the Investigation team leader should contact the relevant Corporate (or Unit) Functional Discipline Head to participate, as advisers, in the investigation and analysis. For example, in transport and materials handling related Incidents, advice should be sought from the Corporate Functional Discipline Head for Transport – TLM or MSEM/1 and for Health related Incidents, advice from MCC should be requested. Other assistance is also available from outside of PDO through various contractor organisations with experience in various types of Incident investigation. MSE department can assist in identifying suitable contractors if required.

Table 3 - Investigation Team Suggested Make-up

Potential Risk Classification Suggested Minimum Investigation Team

Low Section Head, PDO Responsible Supervisor, Contractor Representative

Medium Department Head or Area Team Leader, Contract Holder, Contract Manager, Area HSE Adviser

High Director, Department Manager, Contractor CEO / Director, HSE Team Leader

These are suggested minimum team compositions. It is entirely up to the Incident owner to assign his investigation team based on the expertise of his personnel. The Incident owner is accountable to his Director and the Managing Director for the quality of his investigation and report. Normally a joint investigation conducted with any involved contractor is preferred; however, should a Contractor wish to conduct a separate investigation according to its own procedures and processes, then it is free to do so. In this case, it is strongly recommended that the Incident Review Committee reviews the Contractors' associated Incident report at the same time of the review of PDO's Incident review.

1.3.2 Investigation Timing

Investigations should take place as soon as possible after the Incident has occurred. The quality of evidence can deteriorate rapidly with time, and delayed investigations are never as conclusive as those performed soon after the event. Important evidence can be gained from observations made at the location, particularly if equipment remains as it was immediately after the Incident. In the case of fatal Incidents and Road Traffic Accidents, the scene must not be disturbed until permission is obtained from local ROP Senior Officers.

In this case the scene and all evidence should be preserved to prevent deterioration as much as possible.

1.3.3 Background information

Page 8 Incident Investigation, Analysis and Reporting Guideline Printed 17/08/08

The controlled version of this CMF Document resides online in Livelink®. Printed copies are UNCONTROLLED.


Background is required on the following for most Incidents:

General Procedures and Standards for the type of activity/operation being carried out at

the time. These may include departmental instructions, safety regulations, written

instructions, permit to work, policies and contract scope of work.

Location plans and road maps etc. Organisation charts showing local command structures and listing persons involved. Responsibilities, experience and training of personnel involved. Contingency plans / emergency response procedures. Hazard management controls which should be in place according to the provisions of

the Contract HSE Plan, applicable Safety Case(s), Hazard Control Sheets and Job Safety Plans.

1.3.4 The Investigation Process

General

In general the investigating team should consider the following points:

1. Confirmation of the potential severity and probability of the Incident happening again ( i.e. risk to PDO )

2. The need to establish as many facts as possible to properly understand the events surrounding the Incident and, to establish the sequence of events.

3. Where information is absolute fact this must be stated with supporting evidence. If any information is the result of supposition or a reasoned assumption then this must also be made clear.

4. The need to address the question of 'WHY' an act or condition was not recognised, or was recognised and tolerated. Keep asking 'why' until no more fundamental reasons or causes can be found. Try to establish not only the immediate causes, but also the underlying and root causes.

Immediate actions at the incident site:

Ensure the scene is safe for you to enter The injured person needs looking after Secure the incident scene Isolate all machinery/equipment, make notes of status Identify and preserve all physical evidence Record details of the scene, photographs/video/sketches Identify all possible witnesses

A structured checklist, in the form of a guide has been developed from various sources to help maintain the required breadth of inquiry. The scope of the investigation is divided into four areas:

Prevailing Environment People Organisation Equipment

In each section a number of basic questions cover the general scope of the investigation, while the follow-on questions should be addressed where faults or unsafe conditions are found. The follow-on questions in some cases lead to one of the other general areas. The guide may also assist in identification and classification of causal factors for recording and analysis purposes.

There are at least eleven core areas of investigation:

1. The Injured person (IP)




You have to find out as much as possible about the injured person to be able to see the incident from his point of view. You have to be able to get inside his head at the time of the incident to be able to understand it.

One of the problems you may encounter is the IP is not immediately available, this results in you conducting the investigation and drawing conclusions prior to getting his version of events. Beware, the IP interview may put a whole new twist on events

1. Name, age, service with the company2. Medical condition and medical results3. Experience in role doing at time of injury4. What was he employed to do?5. What activity was he doing when injured?6. Was he authorised to do the activity?7. Was he competent in conducting the activity?8. Is there evidence of competency through training or instruction

in the job?9. How many hours had he worked that day?10. How many hours had he worked that week?11. Had he reported feeling sick or poorly?12. Was he happy about doing the activity?13. How many hours had he driven?14. How many hours did he have to go in the journey?15. Had he complained of problems relating to the activity or

equipment prior to the injury being sustained?16. What motivators were there for the employee to potentially

break rules?17. What is his character like?18. What is his previous incident record like?19. What is his training attitude like?20. What is his attitude to rule breaking like and diligence?21. Had he just changed roles recently?22. Has he been doing the same job for many years?23. What did he do before being employed by you?24. Had he been inducted in health and safety and when?25. What is the content and make up of the training received?26. Can the company confirm through evidence the content of the

training and instruction?27. Can the company confirm through evidence the competency of

the trainer or instructor?28. Did the employee confirm he understood through testing?

2. The Equipment:

The equipment is often immediately blamed for the cause of the incident.. “The equipment was faulty…. the brakes failed….. the steering jammed”

It is therefore essential to evaluate the equipment’s part in any causation of the incident itself

1. Record the serial numbers/number plates of all of the equipment involved in the incident to avoid confusion

2. Was the equipment the correct equipment for the task?3. Visually check and record the state of the equipment at

the scene4. Record all such defects as found and make a judgement

whether they occurred as a result of the incident or not Test and inspect the equipment to ensure it was in a good state of repair. Do so with someone who knows about the equipment as soon after the incident as possible

5. Was the equipment being used in the correct manner?6. Review the servicing and maintenance records for the

equipment7. Review whether pre-shift checks had been conducted

for the equipment, the results and any follow up8. Identify the history of the equipment in relation to

defects, complaints or previous incidents it was involved in.9. Check if a cause of the incident was due to equipment




not being used when it should have been10. Check where equipment had not been used as required,

that it was available to the employee11. If not available then check if employee raised it as an

issue and if so what happened as a result12. Was any PPE needed to use the equipment13. Was the correct PPE being worn correctly14. Identify if the correct PPE had been issued15. What was the condition of the PPE

3. The Environment

The environment can have a significant influence on the causation of an incident. There are two types of environment

Static environment – building layouts, road layouts, structures

Dynamic environment – state of floors, road surfaces, spills, skid marks, lighting, heating, weather, animals, personnel, traffic etc

Static Environment

1. Will change very little over time. 2. The investigation will need to record:

- The workplace or road layout- Signage, road or walkway markings- Distances, to-from junctions, between machinery- Ambient conditions; machinery noise etc- Topography of surrounding area- Anything else nearby which may have a bearing

on the incident; children’s play area etcDynamic Environment

1. Dynamic environmental conditions are lost immediately after the incident. It is therefore of utmost importance to capture as much information on the immediate environment as quickly as possible.

2. For example in an RTA investigation traffic flows may be completely different at different times of day or even on different days.

The investigation will need to record:

1. Weather and lighting conditions at the time of the incident2. Positions of related objects, bodies, debris3. Positions of controls, status of equipments4. Skid marks, spills, (or puddles), 5. Dust conditions6. Ground conditions & the state of it

4. The Third Parties

Third parties are the other persons who were involved in the incident except the injured employee

Third parties are difficult to involve in our investigations as they either

1. Are dead2. Are injured and in hospital3. Have left the scene before our attendance4. Are upset and do not want to talk about it5. Are uncooperative as they do not want to incriminate

themselves6. Can not communicate in English7. Embellish the truth to their own ends and means




In dealing with third parties remember:

1. We have no legal jurisdiction over them and can not force them to provide information

2. They may be in shock and so do not hassle them3. Liaise with the ROP as much as possible to ascertain what

they have managed to discover4. Any information they give you is to be treated as hear-say5. Remember the cultural differences which may be involved

5. The Other Parties

The incident could have been witnessed by other persons not directly involved in the incident

They can be useful to allow you to build up a mental picture of what has occurred and information can be collected informally

When collecting evidence from other parties be aware:

1. They may not be impartial to the persons involved in the incident (rig move staff, well engineers etc)

2. They may embellish what they have seen to make it more exciting, (who wants to relay a boring story)

3. What they think they saw may not in reality be true as it is their perceptions they are relaying to you

4. Collecting perceptions from a number of different witnesses allows you to make an informed judgement of the event

5. You have no rights or jurisdiction on that person6. They are ‘volunteering’ information attempting to formalise it

may make them withdraw7. Chat with them, ask questions, be interested8. Don’t start making notes, write it down later9. Distinguish facts from opinions10. If using an interpreter, ask short questions, wait for the

answers11. Don’t argue with them, if you or they are unclear act

confused by the point, they may fill it in for you

6. The activity taking place at the time

The incident will always involve an event taking place at the specific time the injury or damage was caused

It is often very easy to identify the event which was taking place, it is more difficult to analyse the event and identify whether or not it was the correct event or was being done correctly

When identifying the activity determine the following

1. Was the activity part of the normal task conducted? 2. Would the activity appear to have been done correctly? 3. Is the activity difficult or complex?4. Is the activity itself risky or dangerous?5. Has the activity itself been documented and risk assessed?6. Is there evidence of shortcuts been taken?7. Is it an activity which is open to shortcuts?8. Is the activity commonly conducted or a rare event?9. Is the activity an every day occurrence in the field by other

persons?10. If so, can other persons comment on the shortcuts or problems in

conducting the activity?11. Are there any particular circumstances which might have led to the

activity been done differently this time?12. Is the activity a relatively new activity or new equipment or has it

taken place for many years?13. What are the controls which should be in place as a result of the




risk assessment?14. Is there evidence that these controls were or were not in place?15. Are the controls which are in place adequate for the level of risk

posed by the activity?

7. The activity taking place before hand

Sometimes the activity taking place before the event is as crucial as the event itself

The activities prior to the event and even the day before enable you to understand more about the frame of mind of the injured person, his potential motivations and what led him to do what he did (if relevant)

The length of time analysed before the incident will depend on the nature of the event itself

1. Ask the injured person or persons with him to talk through the events of the shift from the start, clarify timings with the interviewee

2. Ask them what they had done on the previous shift and the time between shifts

3. Ask them to elaborate on anything which you feel could be of relevance to the investigation

4. Cross reference what they have described, involve other people to confirm that they have their facts correct.

5. Question any discrepancy between their account and that which you know to be fact or deviations from procedures, journey plans or other accounts.

6. Do not make them feel they are being cross examined, they will dry up.

8. Historical information

Sometimes during the investigation or interview you may find that this is not the first incident of this kind. Reviewing the findings of the previous investigation can add value to yours. Do not though assume the causation is precisely the same by default.

It may also be that discussions have been ongoing relating to a potential problem. If you can, review any minutes etc from these discussions.

1. Check with management if issues relevant to the incident have been raised before

2. Collect any evidence of such issues being raised3. Follow the evidence trail of the issues raised in relation to who were

involved, how they were involved, what actions were taken, what actions were not taken

4. Identify if, where actions were not taken, could they have prevented this specific incident if they had been

Check

1. Minutes of meetings2. STOP cards3. Near miss reports4. Emails5. Letters and memos6. Complaints made or escalated7. Ask people if the risk had been raised historicallyImportant note

Only raise issues in the report if they are directly linked to the causation of the particular incident you are investigating. Do not increase the scope of the investigation to other failures which are not relevant, they should be dealt with separately

Records and Procedures

1. Records such as 'as built' drawings, instrument records, computer printouts, log books, transport documentation and time sheets

2. Previous Audits and Incident investigation reports3. What procedures exist for tasks being performed at the time of




the Incident4. Instructions and Procedures such as Permit to Work 5. If a Procedure was not followed, try to establish why it was not

followed: was it not known; not fit for purpose or, was there some other reason

9. The hazard and risk equation leading to Root Cause Analysis

A risk assessment identifies the potential for an incident to occur. It identifies the hazard, something which has the ability to cause harm.

The risk is simply the likelihood that the harm will be released

An incident means the harm has actually been released

Identify where a particular condition was over-riding in its impact or whether a combination of several conditions combined led to the hazardous situation arising.

Use the domino principle

Unsafe act by individual, competency, training and instruction, standards of supervision, management philosophy poor planning or design, deficient management policy, expenditure or high level decisions

1. Work back from the known point of injury and identify the actual hazard which led to the injury or the damage being caused.

2. Identify the primary conditions which led to the circumstances where the person could be harmed etc

3. Identify the secondary conditions which led to the circumstances creating the primary conditions

4. Continue repeating this until such time as you hit the core conditions which enabled the chain of events to start

5. Note that several primary or secondary conditions can result which all need investigating and resolving as separate paths

6. For each condition or circumstance which contributed to the incident identify the combination of controls which could have been in place to prevent it arising

7. Identify if there was ‘custom and practice’ where the official controls are ignored habitually

8. Now identify the different manner in which the controls which could have been in place can potentially fail and thus be nullified

9. Record the conditions, circumstances, possible controls and potential failures of such controls

10. Use the ‘5 Why’s’ to try and find the answers and to keep digging down until you discover a root cause

10. Witness Statements

Witness statements can be vital in determining the outcome of the investigation.

Remember you are not interrogating the witness, you are trying to solicit information which will help you to piece together the chain of events.

They must be conducted in a timely and professional manner.

Try and collect statements in the following order:

a) Injured personb) Witnessesc) Line management

1. If the injured person is unable to be interviewed gather as much evidence as possible from witnesses.

2. If unable to interview the injured person ask him to write down whatever he remembers of the incident for you to review later.

3. Prepare for the interview, ensure you have privacy and any equipment/information you may need beforehand.

4. If the witness wishes to have someone present allow it but do not allow them to answer questions for the witness unless translating.Identify the witness, make sure you have names, contact details etc correct.

6. Put them at ease, ask how they are feeling etc, explain the purpose of the investigation, (incident prevention) to them and introduce yourself, even if you know them.

7. Use a chart or sketch of the incident scene if necessary to locate




the positions of all witnesses.

LISTEN to the witnesses, allow them to speak freely, be courteous and considerate. Let them put forward their version of events.

1. Try not to stop the flow, if you are unsure or the witness goes off track try to bring them back gently by asking them to explain a point in more detail.

2. Take notes and type the interview up as soon as possible, certainly before the next interview as you will not remember who said what later. Provide a copy to the witness if requested.

3. Word each question carefully and be sure the witness understands. Use a combination of open and questions.

4. Open – to elicit information; ‘ what did you see?’5. Closed – to clarify a point; ‘ did you see the truck?’6. Be sure to distinguish facts from opinions7. Be sincere and do not argue with the witness.8. Use the interview to attempt to clarify any points you are unsure

of.9. Not all people will react the same to a particular stimulus, a

witness close to the event may have a completely different version to someone who saw it from a distance.

10. Stories may change with time and contact with other witnesses.11. A traumatized witness may not be able to recall all the events12. Witnesses may omit entire sequences for various reasons such as

failure to realize their relevance, failure to observe, personal reasons, bias etc.

11. Chain of events

In any investigation it is always important to ensure that the evidence which you have gathered as part of the investigation can be relayed back to the actual incident.

All photos need to be date stamped and named and signed on the back by the person who took the photographs. Number each photo so they can be refered to in meetings by its reference number

Any notes or sketches which are made as part of the investigation should be kept in the investigation file and marked as ‘working papers’. Each page should be individually labelled, for instance WP1 or WP2 etc.

This is important as you may need this to clarify a statement you have made in the investigation report

Ensure all documents which you have collated as part of the investigation are also labelled for example E1,E2, E3 and then ensure that you label how many pages each document contains, e.g. page 1 of 2, page 2 of 2.

Keep all of your relevant documents together and order them in an investigation file so that

1. Ensure an investigation file is created which has all of the supporting documentation from the investigation

2. Hazard and effects 3. Working papers4. Risk assessments5. Inspection records6. Procedures7. Previous incidents8. Training records9. Maintenance records10.Employee records11.Photos and sketches12.Witness statements13.Guidance documents14.Health records15.Pre-shift check records16.Minutes of safety meetings 17.Previous complaints18.Pass the file to HSE Dept on completion of the

investigation.




they can be catalogued and create an index. Create the investigation report in the

required format calling on information which should be readily available from the investigation file.

Incident reporting

Do not be ruled by the form – ask other questions continually throughout the investigation. Keep the purpose of the investigation in mind at all times, (prevention of re-occurrence). Do not fall into the trap of immediately blaming the IP/employee and suggesting remedial training. The objective of the low potential form is to carry out a simple investigation and provide meaningful

corrective actions asap, as mentioned the form may be re-submitted if root causes cannot be immediately established.

Medium and high potential incidents require a more in-depth investigation. Use the template provided for a full report, this will be going on the website in the next few weeks. PDO require a Tripod beta analysis for all high potential and fatal reports. They will do it. You will be being investigated by the ROP as well as investigating internally in most fatalities.

The construction of a diagram showing the connections between the various events and conditions leading up to the Incident - an Incident tree - has proved to be an essential tool in determining the underlying causes and conditions leading to an Incident.

For High Potential Incident & fatality investigations, a process known as Tripod Beta should be used to develop an Incident causation tree. Unit or Corporate HSE Advisers should be approached to assist in this. Tripod Beta uses a specific logic methodology which is extremely powerful in determining root causes of Incidents.

Preserving Physical Evidence

In some Incidents components or equipment may be damaged or have failed. In these cases, the equipment should be lodged in a secure place pending more detailed analysis.

Conducting Interviews with Witnesses and Supervisors

Conducting Special Studies

Incidents of an involved or complex nature can require the analysis by specialists to determine causes of failure. Aircraft crashes, crane failures and explosions are examples of such Incidents. This should rapidly be identified and the specialists be involved early in the site assessment. Requests should be made to the appropriate Corporate Functional Discipline Head(s) to assist in the provision of such specialist support as required. The investigation team should ask whether the ROP or the relevant medical officer have conducted any tests to determine if alcohol or drugs may have contributed to the Incident.

'Rules of Evidence'

The investigation team leader must avoid the presentation of supposition as though it were fact. Whilst it may be appropriate, sometimes even necessary, to evaluate the most likely cause(s) of an Incident on the balance of probability, it must be avoided where the implication is that somebody specific was responsible for the Incident. In such situations, the investigation must limit itself to the facts. This is especially important if there is any possibility that criminal proceedings may result. Supposition or assumption should be clearly stated as such and not confused with fact. Remember that the main purpose of Incident investigation is not to assign blame to individuals.

Underlying causes and human factors

The initial stages in an investigation normally focus on conditions and activities close to the Incident and only Immediate Causes may be identified at this time. However, the conditions underlying these




causes will themselves need to be investigated. As the extent of above physical factors surrounding an Incident become clear, the investigator(s) should shift the emphasis of their investigation and questioning to the underlying causes and to the reasons for peoples' actions. This will allow for ease of assessment when analysing the Incident. It may be necessary to take a closer look in the following areas:

Engineering design Operating procedures and philosophies Equipment selection Planning methods Job responsibilities and descriptions Discharge of HSE responsibilities Organisational relationships HSE systems and Control systems Training methods and experience criteria Working/duty hours policies and practice Internal safety inspections/auditing Contract conditions and control Maintenance procedures and records Testing methods and records Communication and availability of information Abuse of alcohol or drugs

It should be noted that an investigation confined to immediate surroundings of the Incident will only be able to identify localised causes. Recommendations will therefore, only be able to deal with local problems and will not be effective in preventing similar Incidents elsewhere or involving other groups of workers carrying out different but related tasks. In all cases, systematic investigation should ensure that possible causes are considered both in the

range and depth appropriate to the Incident.

Analysis of findings and drawing conclusions

The purpose of the analysis stage is to identify critical sequences of events and to draw conclusions with respect to immediate and underlying causes.

Data may be in the form of:

Hard evidence: data which usually is not disputed such as written records, evidence of physical conditions, photographs of the undisturbed site, tests for alcohol or drugs etc.

Witness statements from people present at the time of the Incident and immediately afterwards.

Reports of tests carried out since the Incident. Circumstantial evidence: the logical interpretation of facts that leads to a single, but

unproven conclusion.

Identification of recommendations

The final list of recommendations for action should include AT LEAST ONE action against each identifiable cause. It should be noted that not all causes can necessarily be eliminated, and some may only be removed at prohibitive cost. Some recommendations will therefore aim at reducing a hazard to a minimum, practicable level, others at improving protective systems to limit the consequences.

Recommendations should be SMART : Specific; Measurable to the extent that it is clear when they have been implemented; Achievable, Relevant to an identified cause (immediate or underlying) and have a Target completion date assigned. Statements such as the following are expressions that DO NOT satisfy these requirements!

'Drivers should take more care......




'Supervisors should ensure that

'The rules for..... should be followed.'

'More attention should be given to......

Recommendations should be structured corresponding to the failed barriers. Description of actions should be worded in such a way as to clearly indicate how the Incident follow-up coordinator will know when the action is complete.

The wording and target due dates for each action shall be agreed with each assigned action party before the report is submitted to the relevant review committee. If agreement can not be reached then this difference in opinion must be highlighted to the appropriate review committee who shall decide if the recommended action is valid or not.

Recommendations should generally be restricted to the key issues which contributed to the Incident being investigated. They should address actions which are necessary to ensure that failed or missing controls or barriers, which would have prevented the Incident and/or reduced the consequence, are in place in the future. The reason for this is to sharpen the focus on the specific learning points from the Incident. If other areas for improvement, which did not have a significant impact on the specific Incident, become apparent during the investigation process, then these should be communicated to the relevant person for action outside of the Investigation report as part of PDO's normal business process.

1.4 Incident Reports

The degree of reporting required in the event of an Incident is determined by the potential severity of the Incident and the probability of a similar Incident re-occurring. Refer to the Incident HSE Risk Matrix

Reporting of Low Potential Incidents, is limited to a completely and accurately filled out Notification form - either a Health and Safety Incident form or an Environmental Incident form.

All other Incidents require a more formal Incident Report in addition to the Notification. Two different types of Incident Report exist for Medium Potential Incidents - one for each of the following types of Incident:

Guidance on completion and routing of general Incident Reports is also provided in Appendix 3

A more comprehensive and detailed report is required in the event of a High Potential Incident. A template for such a report is also provided in Appendix 1.

A simplified report is required in the case of a non-accidental sudden death of a person employed by or on contract to PDO. A template for this special report is also included in Appendix 2.PDO's medical department can assist in the completion of this report.

1.5 Implementation of Recommendations

Implementation of action items must be formalized for effective follow-up. All actions must be tracked through FIM. In addition, it is necessary to inspect/audit at periodic intervals to ensure that improvements have been sustained.

2: Ownership of Incidents

Incident ownership is a term used to designate PDO single point responsibility for ensuring that an

Incident is investigated, reported and followed-up according to the requirements set out in this

document. Ownership is first assigned to a PDO Responsible Supervisor and then delegated to the

appropriate level within that Line for action. The organisation Line in this respect refers to PDO's

reporting Line from MD to Director to Line Manager to Department Head to Section Head, etc. Within




any given organisation Line, certain individuals are designated as Asset Managers, Contract Holders,

Site Representatives, etc. in line with the Asset Management or Contract Holdership responsibilities.

There are two types of Asset Managers – Product Flow Asset Manager and Service Provider Asset

Manager. There are also Process Owners e.g. UEOD for Engineering and Operations Processes,

Risk Advisors/Managers e.g. MSEM for HSE Risk and Skills Pool Managers (CFDH’s). Each

Manager is directly accountable to the MD for the performance and development of his/her asset

including staff resources, however various assets are organisationally grouped together under a

Director who is responsible for the group of Assets under his/her control.

From time to time, depending on the activity, an Asset Manager (AM), such as a product flow AM,

may grant authority over a defined portion of his assets to another AM, such as a Service Provider

who then becomes an Asset Custodian. The Asset Custodian then assumes full responsibility, on

behalf of the Asset Manager, for all activities and assets within that defined area.

The Service Provider AMs provide common services to support primarily the product flow Asset

Managers. These services include drilling, logistics, seismic, finance, telecommunications, etc. Some

of these Service Provider departments are organised within the same Directorate, or Line, as the

Asset Managers and others are organised into separate Lines such as the Drilling Engineering and

Exploration departments.

All Incidents are required to be investigated and reported, according to this document, ultimately to

MD who in turn is required to report elements of PDO's corporate performance to PDO's shareholders

according to separately agreed requirements. The designation of Incident ownership within PDO is

therefore a structural means by which PDO may systematically investigate, report and follow-up any

HSE Incidents which occur in the course of running the business. The ultimate aim is to manage

PDO's activities in line with the corporate policies.

Line Incident ownership is determined according to the following criteria which are aligned with PDO's

structure of Asset Managers and Service Providers. Incident ownership should normally rest with

the reporting Line which has most influence over the site or activity.

The purpose of defining clear criteria for Incident ownership is to ensure that in every event,

clear rules will always lead to positive Incident ownership immediately after the Incident so

that no time is lost in carrying out the investigation. It is understood that the criteria below

may not always be the most fair in light of the prevailing circumstances. However if the rules

are applied consistently and immediately, the benefit will outweigh any harm.

a) If the Incident, excluding transport related Incidents, occurred within one of the

following Asset Manager areas of operation, then ownership rests with the reporting Line of that

designated Asset Manager: any interior operational facility, installation or Operations asset such as:

- plants, pumping & compression stations,

- well sites,

- PDO & Contractor interior offices, camps, workshops & recreational facilities,

- flowline or pipeline rights of way, etc.

- any area of common use within the physically fenced coastal office and industrial area

b) If the Incident, excluding transport related Incidents, occurred within an area where holdership

was temporarily transferred, in a written agreement, to an Asset Custodian, then ownership rests

with the reporting Line of that Asset Custodian. This would normally apply to any:




- drilling and service rig locations and associated camp sites,

- seismic operational areas and associated camp sites,

- supply warehouse and storage areas

- green-field construction sites

- fenced off or access controlled areas of existing facilities where only construction or

maintenance activities are underway

- interior contractors' facilities where only one PDO Contract Holder or Service

Provider is designated as accountable for those facilities

- PDO School and Ras al Hamra Recreation Centre

- defined areas within the Main Office complex.

c) If none of the above criteria are definitive, still for non-transport related Incidents, then Incident

ownership rests with the reporting Line responsible for supervising the activity during which the

Incident occurred. This rule shall then apply unless the involved parties have a documented

agreement in place which clearly defines alternative roles and responsibilities. Such a documented

agreement may take any form (e.g. a corporate procedure or an agreement covering the supply of

labour from one party to another) provided that it clearly states respective roles and responsibilities

and, is accepted by both parties.

It is therefore important for all parties who make such agreements to keep copies of the agreements

in case there is a dispute.

For all transport related Incidents (except milk run journeys without a single contract holder as

described in item 5 below), PDO Line ownership rests with the reporting Line of:

the person in control of each vehicle at the time of the Incident if that person is directly

employed by or seconded to PDO, or

the Contract Holder of the relevant Contract in control of each vehicle at the time of the

Incident.

If more than one PDO reporting Line is involved then Line ownership rests with the PDO reporting

Line which suffers the most severe injury, or the most damage if no injury is sustained, as a result of

the Incident. In the remote instance that all injuries and damage are equal then MSEM shall assign

Incident ownership based on his perception of which Line had most influence over the activity or site

at the time of the Incident. In the absence of MSEM, the acting MSEM shall make this decision and

this decision shall be final. In such an instance, the Incident should be investigated and reported

jointly with participants from each of the involved Lines and with the Incident Owner leading.

d) A special procedure exists if a transport related Incident occurs during a "milk run" journey

where one journey was being used to supply or service more than one site or contract, whether for

PDO, a PDO active Contractor or a third party and where there is no single Contract Holder or

manager accountable for that journey. For the purpose of determining Incident ownership, the

journey shall be divided into discreet sections. Each section shall have a beginning or "dispatching"

location and an end or "receiving" location. Each journey section shall progress from departure from

the dispatching location until arrival at the next receiving location. Incident ownership for each section

of such a milk run journey rests with the reporting Line of the Asset Manager or Service Provider (as

described in items 1, 2 and 3 above) which has the most influence on that section of the milk run

journey. To avoid debate on the significance of the degree of influence, for the purpose of




determining Incident ownership, dispatchers are considered to have more influence than receivers.

Therefore, Line ownership rests with the reporting Line of the dispatching location of the relevant

section of the milk run journey.

Incident ownership for the first section of such a milk run journey, from the home base to the first

receiving location, also rests with the reporting Line of the first receiving location. This also applies if

the first location is a supply warehouse or yard such as at MAF. If the Incident occurs on a section of

the journey where the last dispatching location was a third party or non-active Contractor, then for the

purpose of determining Incident ownership any third party or non-active Contractor location shall be

ignored and ownership shall flow through to the last PDO or active Contractor dispatching location.

An example of the above procedure is shown in the diagram below with the arrows showing the

journey sections and direction of travel and with the Incident owners shown in bold italics beside their

assigned sections of the journey. Where an agreement is also in place as defined in items 1, 2 or 3

above, then ownership for each section of a milk run journey would also pass to the asset custodian

or service provider who required the supplies or services to be brought to their respective locations.

Figure G1 - Milk Run Journey Incident Ownership

3rd Party

HOME BASE

SERVICE RIG SEISMIC CAMP

PRODUCTION STATION

(SERVICE RIGASSET HOLDER)

(SEISMIC CAMPASSET HOLDER)

(OPERATIONSASSET HOLDER)

(SUPPLY YARDASSET HOLDER)MAF Supply

Yard

(SUPPLY YARDASSET HOLDER)

It is important to note that this determination of Incident ownership shall not affect the well established

journey management system where the journey manager is fully responsible for planning the entire

journey wherever he is located.

e) Once Line Incident ownership is determined, the authority level within that Line at which Incident

ownership normally rests is determined on the basis of Incident potential according to the HSE Risk

Matrix reproduced in Figure G4 below. Three levels of authority exist to cover the three classes of

potential risk to the Company – Director level, Department Head / Area Team Leader level and

Section Head Level.

Figure G1 - Incident Ownership Level of Authority

Potential Severity Limit to Delegation – Incident Owner

Low Responsible Supervisor

Medium HSE Team Leader

High (without fatality) Manager

High (single fatality) Director




High (multiple fatality) MD

Although the entire generic matrix is shown for completeness, for practical purposes columns A and B

will rarely if ever be applicable for potential risk assessments. Also, a potential risk of 0 is irrelevant

and therefore row 0 shall never be used in this context. Most PDO Incidents then will fall in the range

between severities 1 to 4 and probabilities C to E.

The person identified as the normal Incident owner in Figure G1; however, has discretion to delegate

responsibility for investigation, reporting and follow-up according to his / her assessment of the merits

of the learning value for the case in question and according to the specific capabilities of his available

personnel. It must be emphasized that the Incident owner is still accountable for the quality of this

work. The limit to delegation is determined on the basis of Incident actual outcome, not potential

outcome, as follows:

Table G2 - Limits to Delegation for Investigation

Actual Severity Limit to Delegation

0, 1 & 2 Responsible Supervisor / Section Head

3 Department Head

4 Manager

5 Director

Investigation and reporting of a non-accidental death may be delegated to the Section Head

level provided that there are no apparent unusual circumstances surrounding the death.

Example

A driver was rushing to return to his camp at the end of a long day. At a distance of 40 km from his

destination he rolled his vehicle over. He received a minor injury which subsequently received First

Aid treatment. He was lucky in this respect because he wasn't wearing his seat belt and had no other

passengers with him. He was found by another road user some 30 minutes after the Incident.

There is a reasonable chance that the driver could have been killed and, of a similar Incident

happening again if nothing is done to prevent it. This type of Incident happens more than five times

per year within PDO but less than five times per year in that area or with that rig. Using Figure 4, an

Incident Potential of 'D4(People)' is proposed by the Incident Owner. Upon early review of the initial

notification, the Director learns that the circumstances of the Incident closely resemble those of an

Incident six weeks earlier, for which a thorough investigation had taken place and, various

recommendations implemented. Little benefit would be gained by the Director leading the

investigation into this Incident, so he elects to delegate. Given that the actual outcome was a First Aid

Case (Severity 1), the lowest level to which the Director may delegate responsibility for leading the

investigation & follow-up, is to the Responsible Supervisor level.

3: Organization and ToR for PDO Incident Review Committees

3.1 MD Incident Review Panel (MDIR)

3.1.1 Description




The following describes the Terms of Reference and operation of the Managing Director’s Incident Review Panel, as reiterated in PDO Management Circucular: Rev 1, dd 11/03/2007

3.1.2 Objectives

The MDIR is principally concerned with preventing the recurrence of incidents via the cascade of action items across PDO and Contractor operations, and to act as a forum that allows MDC to hear, at first hand, HSE views from the workforce. It also enables MDC and Contractor CEO’s to assure first line Supervisors of their support for continuous HSE improvement and to raise the importance of effective first line supervision.

3.1.3 Participants

Table G3: MDIRC Participants

Regular Attendees MD, DMD, OPAL Representative, MSEM, MSE5

PDO Attendees by invitation

Appropriate PDO Director, Contractor Holder, Line Supervisor, Asset Managers

Contractor Attendees by Invitation

Contractor MD, first line Supervisor, HSE Manager

Others by Invitation Personnel invited by Asset Manager or Contractor MD where appropriate

3.1.4 Location and Meeting Frequency

The review will take place on Monday afternoon 2 weeks of the incident happening in the Board Room, starting at 13.15hrs and lasting up to 30 minutes per item. Before coming to the MDIRC the LTI will have been reviewed with the responsible PDO director.

3.1.5 Preparation

The preceding Wednesday, MSE/4212 will issue the agenda and timing for the review. Relevant Director, Line Manager, Incident Owner and Contract Holder (when applicable) will be advised.

The preceding Saturday, the Incident Owner shall issue the pre-reading material to MSE/5, who will review and forward to the MSE/4212 for submission to MDIRC members.

3.1.6 Agenda

The Incident Owner will be the secretary for the incident during the review. He will identify those action points with clear lateral learning value for company-wide cascade. MSE/5 will facilitate this process and ensure the learning are cascaded appropriately.

Lessons learned from the review will be published on the HSE website and email sent to all Directors and HSE Team Leaders. Directors and line managers will be required to cascade these lessons within their organisation, and OPAL Representative will cascade same lessons amongst its members via copy of the weekly highlights.

3.1.7 Review

MDIRC will review all LTIs in addition to fatal and high potential incidents.




Besides MDIRC permanent members, the appropriate PDO Director, Incident Owner, Contract Holder and line supervisor are required to be present in the review. The Contractor MD will be invited by the Contract Holder, where contractor staff is involved. Line Director or Contractor MD can invite other personnel where they feel this is appropriate.

3.1.8 Meeting Format

The format of the review remains a round table, with a short presentation by Line Manager or Contractor CEO. The presentation package shall be as per the templates provided (Medium potential LTIs and High potential/fatalities), with the presentation taking no more than 5-10 minutes, allowing 20 minutes for discussion. Incident reports are not required to be submitted at this time, but should be completed within 3 weeks of the review and copied to MSE/421 who will ensure the actions and report are input into FIM.

3.2 Directorate Incident Review Committees (IRCs)

Each directorate will continue to have its own Incident Review Committee (IRC), which will function in line with foregoing MDIRC scheme, as follows:

Each IRC will review LTIs and medium potential incidents that occur within its business area in the preceding week. To ensure coherence, some IRC’s may be set up on the basis of Work Practitioner Groups, e.g. DOIRC, XIRC, etc.

The Director will appoint a focal-point for each IRC who will be responsible for co-ordination of the IRC meetings and ensuring LTI Briefing Packs are prepared within 10 days of the review to cascade lessons across the company.

LTI Briefing Packs will only be issued company-wide by MSE/43 after review to ensure quality and consistency. MSE/43 will provide standards template for the packs.

Minutes of the IRC and action items shall be copied to MSEM and MSE/5/421.

The intention is to continue to hear views from the workforce, raise the importance of the first line supervision and assure supervisors of MDC’s and CEO's support for their HSE tasks. Victimisation is neither allowed nor intended and the reviews will therefore be carried out in an atmosphere devoid of fear.

1.2.1 Committee Establishment

The Directorate IRC’s are established in PDO:

OSIRC (OSD)

ONIRC (OND)

DOIRC (TWM)

TSIRC (TSD excluding TWM)

HIRC (HD)

XIRC (XD)

FIRC (FD)

GIRC (GD)

1.2.2 Composition

Each directorate shall define the permanent members of their IRC, but they will typically be:

The unit director (chairman), who may delegate no lower than a line manager




2-3 Senior department heads (one of which will be vice chairman) Unit HSE Advisor or Focal Point (facilitator, should have attended Tripod-B Incident

Investigation Course) Senior representative of the contractor community (optional) MSEM representative Other ad-hoc attendees could be invited for specific reviews (e.g.: TTO/13 for lifting operation

incidents, MSEM/15 representative for review of any RTA’s) In case of absence, permanent members shall ensure a suitable delegate attends the IRC to

replace them.

1.2.3 Responsibilities

The IRC’s prime responsibilities are:

To review the following classes of HSE incidents for which the directorate is owner, in accordance with this Procedure

High potential near misses (actual severity 0) Actual severity 2/3 and medium potential Actual severity 4/5 and high potential incidents which have first been reviewed by MD-IRC will have a final review and close out by the relevant Directorate IRC.

To ensure consistently high quality incident investigation by the line

To review incidents to a level of detail commensurate with incident potential severity, as determined from the Incident Potential Matrix.

To review and endorse the actual severity and potential risk rating provisionally assigned to each incident.

To endorse corrective and remedial action items to prevent reoccurrence of similar incidents. To assign appropriate action parties and deadline for close out. Note: assigned action parties outside the Directorate’s direct control shall formally agree to accept the action item.

To define the lateral learning items that are to be communicated to others and ensure their rapid and effective promulgation.

1.2.4 Meetings

Meetings may be held weekly at a fixed day/time, and could take place in the interior where incidents occur. However, if no incidents occurred, the unit Director can decide to cancel the meeting. Directorates that, due to the nature of their operations, have relatively few incidents, a monthly or 2-weekly period is acceptable.

A typical IRC agenda could include the following items (at the discretion of the unit Director):

Review status of LTI reports and action items for the directorate Review of new HSE Incidents Learning from MDIR and other IRC’sAn incident should be reviewed within 2-3 weeks of the incident occurring. For an incident to be

reviewed by the IRC, the investigation and draft final report shall be completed and issued to all IRC members prior to the meeting.

Incidents that have first been reviewed by MDIR shall be reviewed by the Directorate IRC (from which the incident originated) within 2-3 weeks of the MDIR session. The incident investigation and report (taking the MDIR proceedings into account) shall be completed before that time.




1.2.5 Lessons Learned

Lateral lessons from each IRC session should be prepared and issued within one week of the meeting. Records should as a minimum include the following for each incident that has been reviewed:

Incident reference no. Actual Severity Potential Brief incident description (including details on the consequences to People, Assets,

Environment and Reputation) Immediate and Underlying Causes Actions to prevent recurrence (with action party and due date) Lateral learning (Lessons Learned) to be communicated

These lessons shall be issued within each Directorate and copied to Focal Points of all IRC’s, assigned action parties and MSEM (MSEM, MSEM/13/42/43).

IRC Focal-Points should ensure that the agreed lateral lessons of key incidents are issued to MSEM/13 within one week of each review as per the standard format provided. MSEM/13 will quality check and issue Lateral Learning sheets for wider dissemination.

LTI Briefing Packs shall be prepared for those incidents with particular high lateral learning value. The draft for these packs shall be made the incident owner, with assistance of IRC Focal-Point, prior to being issued to MSEM/13 for quality checks. Final Briefing Packs will be issued by MSEM by MSEM/43, but may be issued internally (within directorate or asset team) by the IRC Focal-Point

4: Definitions and Explanation of Terms

(as per ICIR Manual – December 31, 2007)

Asset Damage

A direct loss of or damage to plant, equipment, tools or materials resulting from an incident. (Refer to guidance and examples in Appendix 6 of the ICIR).

Business

One of the global Shell businesses, i.e. Exploration and Production, Downstream or Gas and Power.

Business Travel

For a PDO employee, Business Travel is any travel undertaken for the purposes of work activities in which that person is engaged in the interests of his or her employer, to the following extent:

It includes the period from the time that person leaves their residence or their normal place of work until they return or until the time they arrive at their destination and check into temporary accommodation (‘home away from home’).

It includes, on the return trip, the period from when the person checks out of their temporary accommodation until they arrive at their residence or their normal place of work.

It includes the whole spectrum of travel, from international travel through to simple acts like crossing a public road on foot between two company buildings.

It excludes a person’s normal commute to work.




It includes travel to the airport for a business trip from the time an employee leaves home even if that travel follows the same route as their normal commute. If the employee stops in the office first to work, then the period of employee’s business travel starts from the office and not their home.

It excludes that person’s commute from their home away from home to their temporary place of work or a significant detour made for personal reasons.

Any injury or illness occurring during the business trip is considered to be work related for recording, investigation and learning purposes; but not all injuries and illnesses will be recordable for statistical purposes.

Business Travel - Contractor

For a PDO contractor, Business Travel is any travel undertaken for the purposes of work activities in which the contractor is engaged in supplying Shell or one of its subsidiary companies with goods and / or services, to the following extent:

It includes day-to-day travel undertaken by a Shell contractor in the course of carrying out Shell work-related activities.

It excludes day-to-day travel undertaken by the Shell contractor when that person is not engaged in Shell work related activities (such as their normal commute, or any travel undertaken in the interest of their own employer).

It includes contractor mobilization and demobilization when performed under contract with PDO

Business Unit

Activities in one of the Group businesses that are operated as a single economic entity. A business unit can coincide with a Group company or straddle part or all of several companies.

Consequential Business Loss

The indirect loss associated with incidents resulting in asset damage, environmental impact or impact on company reputation. It comprises elements such as loss of production (expressed as profit margin), process unit downtime, product quality costs, cost of environmental clean up, cost of recovery/disposal of waste and cost of reprocessing off-grade material.

The intention is to estimate the order of magnitude of the loss so that the incident can be assessed on the RAM and the appropriate resources put into investigation. It should not be necessary to conduct a detailed accounting of the full range of indirect costs. Consequential business loss should be estimated on a 100% equity basis.

When consequential business loss results from an incident with impact on the environment or company reputation, the consequences should be assessed under both asset damage and the environmental/reputation categories of the RAM and the highest rating used to determine the extent of investigation and follow up.

Company

Company or Group company means a Shell company, a Joint Venture under operational control (JV-uoc), or a Joint Venture not under operational control (JV-nuoc) that has agreed to report its HSE performance and incident data to Group following the reporting methodology detailed in this guide.

Contractor

All parties working for the company either as direct contractors or as subcontractors.

Environmental Impact

The negative impact on the environment resulting from an incident. (Refer to guidance and examples in Appendix 7 of the ICIR).

Exposure Hours




The total number of hours of employment including recorded overtime and training but excluding leave, sickness and unrecorded overtime hours. Exposure hours should be calculated separately for company and contractor personnel.

Time off duty, even if this time is spent on company premises, is not included in the calculation of exposure hours, but incidents during this time should be recorded and investigated. When they meet the work related definition, they should be included in the statistics as recordable incidents.

In many company sites the number of exposure hours can be calculated from computer controlled access or time keeping records. In the absence of more accurate methods exposure hours can also be calculated from a headcount and nominal working hours per person or time writing systems.

In order to meet reporting schedules, exposure hours can be estimated on the basis of the previous data. Corrections can be made at the end of the reporting year when more time is available.

Fatality

A death resulting from a work related injury or occupational illness, regardless of the time intervening between the incident causing the injury or exposure or causing illness and the death.

FAR

The number of fatalities per hundred million exposure hours.

FIM

Fountain Incident Management (FIM) is the Group system for recording incident details, the investigation, classification and action items. It can also issue notifications and reports. Other systems can be used in the interim; but all Businesses and Functions are expected to be using FIM by end 2009. FIM should be used for all potentially work related incidents including those that occur while in “home away from home status”.

Fires and Explosions

Normally taken to mean all fires that necessitated the use of a fire extinguisher or other extinguishing means, e.g. snuffing steam, shut off fuel or switch off electricity supply. Fires with no visible flame, e.g. oil soaked insulation, should also be included. All flammable explosions or overpressure explosions should be included, irrespective of the extent of containment.

First Aid

An incident is classified as a First Aid if the treatment of the resultant injury or illness is limited to one or more of the 14 specific treatments. These are:

1. Using a non-prescription medication at non-prescription strength (2);

2. Administering tetanus immunizations;

3. Cleaning, flushing or soaking wounds on the surface of the skin;

4. Using wound coverings such as bandages, Band-AidsTM, gauze pads, etc.; or using butterfly bandages or Steri-StripsTM.

5. Using hot or cold therapy;

6. Using any non-rigid means of support, such as elastic bandages, wraps, non-rigid back belts, etc;

7. Using temporary immobilization devices while transporting an accident victim (e.g., splints, slings, neck collars, back boards, etc.).

8. Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister;

9. Using eye patches;

10. Removing foreign bodies from the eye using only irrigation or a cotton swab;

11. Removing splinters or foreign material from areas other than the eye by irrigation, tweezers,




cotton swabs or other simple means;

12. Using finger guards;

13. Using massages; or

14. Drinking fluids for relief of heat stress.

Note:When determining whether a prescription medicine was used the normal practise is to apply the definitions used in the country where the incident occurred. However, when making this classification it should be remembered that the intent is to distinguish those more severe situations that require a medical practitioner to use strong antibiotics and painkillers from those that only require first aid. The definition of Prescription Medication may be used as guidance in making decisions between those that are strong antibiotics and painkillers from those that only require first aid.

(2) For medications available in both prescription and non-prescription form, a recommendation by a physician or other licensed health care professional to use a non-prescription medication at prescription strength is considered medical treatment. The definition of Prescription Medication may be used to determine when the prescription strength threshold has been crossed.

First Aid Case (FAC)

Any work related injury that involves neither lost workdays, restricted workdays or medical treatment but which receives First Aid treatment. (Refer to relevant definitions in Appendix 3 – PR1418 Part 1).

High Risk Incident (HRI)

An incident for which the combination of potential consequences and probability are assessed to be in the high risk (red shaded) area of the RAM. HRIs can be incidents that result in injuries, illnesses or damage to assets, the environment or company reputation, or they can be near misses.

Incident

An unplanned event or chain of events that has, or could have, resulted in injury or illness or damage to assets, the environment or company reputation.

Incidents do not include operations, maintenance, quality or reliability incidents which had no HSE consequence or potential. Incidents do not include degradation or failure of plant or equipment resulting solely from normal wear and tear.

Injury

Any injury such as a cut, fracture, sprain, amputation etc. that results from a single instantaneous exposure.

Lost Time Injuries (LTI)

The sum of injuries resulting in fatalities, permanent total disabilities and lost workday cases, but excluding restricted work cases and medical treatment cases.

Lost Time Injury Frequency (LTIF)

The number of lost time injuries per million exposure hours.

Lost Workday Case (LWC)

Any work related injury that renders the injured person temporarily unable to perform their normal work or restricted work on any day after the day on which the injury occurred. Any day includes rest day, weekend day, scheduled holiday, public holiday or subsequent day after ceasing employment.

A single incident can give rise to several lost workday cases, depending on the number of people injured as a result of that incident.

Lost Workdays (LWD)

The total number of calendar days on which the injured person was temporarily unable to work as a result of a lost workday case.




In the case of a fatality or permanent total disability no lost workdays are recorded.

Medical Treatment (MT)

An incident is classified as Medical Treatment (MT) when the management and care of the patient to address the injury or illness is above and beyond First Aid(i).

Medical Treatment does not include: -

The conduct of diagnostic procedures, such as x-rays and blood tests, including the administration of prescription medications used solely for diagnostic purposes (e.g., eye drops to dilate pupils);

Visits to a physician or other licensed health care professional solely for observation or counselling;

The following may not involve any treatment but for purposes of severity classification, will be recorded as Medical Treatment.

Any loss of consciousness

Significant injury or illness diagnosed by a physician or other licensed health care professional for which no treatment is given or recommended at the time of diagnosis. Examples include punctured eardrums, fractured ribs or toes, byssinosis and some types of occupational cancer.

Needle stick injuries and cuts from sharp objects that are contaminated with another person’s blood or other potentially infectious material.

Occupational hearing loss.

Medical removal under a government standard (use the Shell Health Guidelines where no government standard exists).

(i) Note: First Aid carries a very specific meaning for this purpose. Please refer to the definition of First Aid.

The following examples are generally considered medical treatment.

Work- related injuries for which this type of treatment was provided or should have been provided are almost always recordable for Group's statistics:

Treatment of infection

Application of antiseptics during second or subsequent visit to medical personnel

Treatment of second or third degree burn(s)

Application of sutures (stitches)

Application of butterfly adhesive dressing(s) or steri strip(s) in lieu of sutures

Removal of foreign bodies embedded in eye

Removal of foreign bodies from wound; if the procedure is complicated because of depth of embedment, size, or location

Use of prescription medications (except a single dose administered on the first visit for minor injury or discomfort)

Use of hot or cold soaking therapy during the second or subsequent visit to medical personnel

Application of hot or cold compress(es) during the second or subsequent visit to medical personnel

Cutting away dead skin (surgical debridement)

Application of heat therapy during the second or subsequent visit to medical personnel




Use of whirlpool bath therapy during the second or subsequent visit to medical personnel

Positive X-ray diagnosis (fractures, broken bones, etc.)

Admission to a hospital or equivalent medical facility for treatment or observation for more than 12 hours.

The following procedures by themselves are not considered medical treatment:

Administration of tetanus shot(s) or booster(s). However, these shots are often given in conjunction with more serious injuries; consequently, injuries requiring these shots may be recordable for other reasons

Diagnostic procedures, such as X-ray or laboratory analysis, unless they lead to further treatment.

Loss of Consciousness

If an employee loses consciousness as the result of a work-related injury, the case must be recorded as at least an MTC no matter what type of treatment was provided. The rationale behind this is that loss of consciousness is generally associated with the more serious injuries.

Medical Treatment Case (MTC)

Any work related injury that involves neither lost workdays or restricted workdays, but which receives Medical Treatment. (Refer to relevant definitions in Appendix 3).

Near Miss

An incident that could have caused illness, injury or damage to assets, the environment or company reputation, or consequential business loss, but did not.

Non Accidental Death

A death from any cause other than from a work related incident.

Occupational Illness

Any abnormal condition or disorder of an employee, other than one resulting from an occupational injury, caused by exposure to environmental factors associated with employment. An illness is work-related if the balance of probability is 50% or more that the case was caused by exposures at work.

Occupational illnesses include acute and chronic illness or diseases that may be caused by inhalation, absorption, ingestion or direct contact with the hazard, as well as exposure to physical and psychological hazards. (Refer to guidance and examples in Appendix 4 ICIR).

OSHA occupational illness cases will be captured for benchmarking purposes in FIM (and other systems where possible).

Operational Control

See “Instructions on Determining Operational Control” – Appendix 5 of the PMR

Permanent Total Disability (PTD)

Any work related injury that permanently incapacitates an employee and results in termination of employment.

Prescription Medication

1. All antibiotics, including those dispensed as prophylaxis where injury or illness has occurred to the subject individual.

Exceptions: Dermal applications of Bacitracin, Neosporin, Polysporin, Polymyxin, Iodine or similar preparation.

2. Diphenhydramine (Benadryl) greater than 50 milligrams( mg.) in a single application.

3. All analgesic and nonsteroidal anti-inflammatory medication (NSAID) including:

Ibuprofen (such as AdvilTM) - Greater than 467 mg. in a single dose.

Naproxen Sodium( such as AleveTM-) Greater than 220 mg. in a single dose.




Ketoprofen (such as Orudis KTTM) - Greater than 25mg. in a single doge.

Codeine analgesics (Cocodamol, Panadeine, etc.) – Greater than 16 mg. in a single dose.

Exceptions: acetylsalicylic acid (Aspirin) and acetaminophen (paracetamol) are not considered medical treatment.

4. All dermally applied steroid applications. Exceptions: hydrocortisone preparations in strengths of 1% or less.

5. All vaccinations used for work-related exposure. Exceptions: Tetanus

6. All narcotic analgesics (except codeine as listed above)

7. All bronchodilators. Exceptions: Epinephrine aerosol 5.5 mg./ml or less

8. All muscle relaxants (e.g. benzodiazepines, methocarbamol and cyclobenzaprine).

9. All other medications (not listed above) that legally require a prescription for purchase or use in the state or country where the injury or illness occurred.

Note: Where there are apparent contradictions, advice should be sought from a Company physician and reasoning documented.

Potential Incident

An unsafe practice or a hazardous situation that could result in an incident (incident has not occurred).

Reputation Impact

The negative impact on company reputation resulting from an incident. The negative impact can be in the form of adverse attention from media, politicians or action groups, or in public concern about company activities. (Refer to guidance and examples in Appendix 8).

Restricted Work

Any work related injury or illness that keeps the employee from performing one or more of the routine functions associated with their job or a physician recommends that the employee not perform one or more of their job's routine duties.

Restricted Work Case (RWC)

Any work related injury which results in Restricted Work.

Restricted Workdays (RWD)

The total number of calendar days counting from the day of starting restricted work (not counting the day of injury / illness) until the person returns to his normal work.

When restricted workdays follow a period of lost workdays, the restricted workdays are recorded in addition to the lost workdays, but the injury is recorded as a lost workday case only.

Risk Assessment Matrix (RAM)

A tool that standardises qualitative risk assessment and facilitates the categorisation of risk from threats to people, assets, environment and company reputation. The tool is described in detail in the Risk Assessment Matrix (2006).

Road Transport Incident

An incident involving a vehicle driven by a company or contractor employee, whether on or off the road, that has resulted in injury, illness or damage to assets, the environment or the company's reputation, irrespective of the cost of repair or responsibility for cause.

A vehicle is defined as a car, van, light vehicle, heavy goods vehicle, road tanker, bus, motorcycle or any unit under tow, e.g. trailers, caravans, mobile generators.

This definition does not include:

Incidents involving vehicles operating on aprons of public airfields; Damage as a result of normal wear and tear, e.g. minor paint scratches, stone chips, and




mechanical wear and tear; Incidents which occur when the vehicle was unattended, e.g. vandalism or other damage whilst the

vehicle was parked. These would be considered as incidents rather than transport incidents.

Significant Incidents

Incidents with actual consequences that rate 4 or 5 on the RAM. (people, environment, damage or reputation).

Third Parties

Persons or organisations that are not employed by or contracted to a company or contractor.

Total Sickness Absence

Absence from work on grounds of incapacity to work due to any sickness and injury, work related or not, expressed as percentage of total workdays available. All other cases of absence such as pregnancy, childbirth, leave, training and seminars, are not included in the definition of absence.

Total Recordable Cases (TRC)

The sum of injuries resulting in fatalities, permanent total disabilities, lost workday cases, restricted work cases and medical treatment cases.

Total Recordable Case Frequency (TRCF)

The number of Total Recordable Cases per million exposure hours.

Total Recordable Occupational Illness (TROI)

The sum of all recordable occupational illnesses. Cases involving no lost or restricted workdays and no medical treatment or first aid are included. A single exposure can give rise to several occupational illness cases. Contractor occupational illness cases are to be reported when known, but are not to be included in the TROIF.

Total Recordable Occupational Illness Frequency (TROIF)

The number of employee occupational illnesses per million exposure hours.

Vehicle Kilometres Driven

The number of vehicle kilometres travelled during work related activities whilst being driven by a company or contractor employee

Work Related

An injury or illness must be considered work related if an event or exposure in the work environment caused or contributed to the resulting condition or significantly aggravated a pre-existing injury or illness. Work relatedness is presumed for injuries and illnesses resulting from events or exposures occurring in the work environment unless one of the following exceptions applies in its entirety:

Occurs when an employee or contractor is present in the work environment as a member of the general public. In this case it will be included in the 3rd party statistics.

Results solely from voluntary participation in a wellness program or in a medical, fitness, or recreational activity such as blood donation, physical examination, flu shot, exercise class, racquetball, or baseball. On the other hand, if the employee was injured by a trip or fall hazard present in the employer’s lunchroom, the case would be considered work-related.

Involves signs or symptoms that surface at work but result solely from a non-work related event or exposure.

Is solely the result of eating, drinking, or preparing food or drink for personal consumption (whether bought on the employer’s premises or brought in). For example, if the employee is injured by choking on a sandwich while in the employer’s establishment, the case would not be considered work-related. Note: If the employee is made ill by ingesting food contaminated by workplace contaminants (such as lead), or gets food poisoning from food supplied by the employer, the case would be considered work-related.




Is solely the result of doing personal tasks at the establishment outside of the employee’s assigned working hours

Is solely the result of personal grooming, self medication for a non-work-related condition. Or is intentionally self-inflicted

Is caused by a vehicle accident and it occurs on a company owned parking lot or road while the employee is commuting

Is the common cold or flu (Note: contagious diseases such as tuberculosis, brucellosis, hepatitis A, or plague are considered work-related if the employee is infected at work).

Is not a Shell occupational stress case.

Shell uses a wider definition of stress than does OSHA.

The OSHA definition of work relatedness excludes a mental illness (unless it is post-traumatic stress syndrome where it can be tied to a specific workplace incident, or are incidents where the employee voluntary provides an opinion from a physician or other licensed health care professional stating the employee’s mental illness is work-related).

5: INCIDENT REPORT TEMPLATES

Appendix 1 High Potential Incident Reports

Appendix 2 Non-accidental Death Reports

Appendix 3 General Medium Potential Incident Report

Appendix 4 Road Traffic Medium Potential Incident Report

Appendix 5 List of Activity at time of Incident

Appendix 6 Broad Incident Types

Appendix 7 List of Immediate Causes

Appendix 8 List of Underlying Causes

Appendix 9 List: Facilities / Plant / Equipment

Appendix 10 List of Injury / Occupational Illness

Appendix 11 Classification of Occupational Illnes

Appendix 1: High Potential Incident Reports

The contents of High Potential Incident reports should be based on the following template or alternatively the Tripod Beta report format can be printed if a complete Tripod Beta analysis has been done:

(This is the information required by PDO and SIEP.)

1. SUMMARY

2. INCIDENT DETAILS

2.1 Time, Date, Place

2.2 Persons involved in the Incident

2.3 Vehicles / equipment involved in the Incident

2.4 Events leading to the Incident

2.5 The Incident




2.6 Description of damage

2.7 Nature of injuries

2.8 Post Incident response

3. INCIDENT INVESTIGATION

3.1 Investigation Team

3.2 Examination of site conditions

3.3 Examination of vehicles / equipment (including maintenance)

3.4 Examination of the work preparation / work task analysis

3.5 Experience, competence and other details of persons involved in Incident

3.6i Sections to address any other issues specific to nature of Incident

3.6ii e.g. Supervision, Procedures, Permit to WorkJourney Management etc.

3.6iii Explicitly describe what action has been taken to determine if alcohol or drug use

was involved

3.7 Response to the Incident

3.8 Incident Tree

4. SAFETY CASE GOVERNING OPERATION / ACTIVITY

4.1 Is activity addressed in Safety Case, and were hazards adequately recognised?

4.2 Were recommended hazard / threat control measures implemented?

5. HSE MANAGEMENT

5.1 Organisation, roles and responsibilities

5.1.1 PDO

5.1.2 Contractor / Contract

5.2 HSE requirements for contract

5.3 HSE Plans (focus on issues which are implicated in causes of Incident)

5.3.1 PDO

5.3.2 Contractor

5.4 Monitoring implementation of HSE Plans

5.4.1 PDO monitoring if PDO is fulfilling responsibilities and obligations

5.4.2 PDO monitoring if Contractor is fulfilling responsibilities and obligations

5.4.3 Contractor monitoring if it is fulfilling responsibilities and obligations

(above sections include monitoring, auditing, inspections, reviews etc.).

5.5 HSE performance of contractor

(On contract in question and other contracts in general. Alternatively, address

PDO HSE performance if a PDO fatality)

6. CONCLUSIONS

6.1 Primary or Immediate cause of the Incident

6.2 Underlying or Contributory causes

6.3 General conclusions and observations

7. RECOMMENDATIONSPage 35 Incident Investigation, Analysis and Reporting Guideline Printed 17/08/08



7.1 Immediate actions

7.2 Follow-up actions

LIST OF ATTACHMENTS (including action Close-Out form template)

Appendix 2: Non-accidental Death Reports

Where non-accidental death occurs to a person who is currently employed by, or on contract to, the Company, records of medical pre-employment checks, periodic medical checks, information about the work and work conditions preceding the death should, if available be subject to investigation. This also applies to non-accidental deaths outside normal working hours. The objective of this investigation is to ascertain whether the cause of the fatality relates to systems and conditions which are managed by the Company and may provide the grounds for corrective action. If this is the case, such a fatality should be reported immediately and be included in the Company statistics. The contents of Non-accidental death reports should be based on the following template where relevant. This is the information required by PDO and SIEP.

1. SUMMARY

2. EVENT DETAILS

2.1 Time, Date, Place of Death

2.2 Details of the Deceased

2.3 Nature of injuries/cause of death

2.4 Sequence of Events leading to the discovery of the deceased

2.5 Sequence of Events following the discovery of the deceased

2.6 Post Incident response

2.6.1 Where death occurred within the Company fence, were the Company Medical

Emergency Response (including First Aid, Medical Treatment and Medevac )

procedures suitable and complied with?

3. INVESTIGATION DETAILS

3.1 Investigation Team (including medical officer or occupation health adviser)

3.2 Persons Interviewed

3.3 Examination of relevant site / living conditions (vehicles, equipment, accommodation, etc.)

3.4 Examination of the work hazards

3.4.1 Are there any work related exposures e.g. contact with hazardous substances, poor working environment etc. which could have contributed to the death?

3.5 Evaluation of pre-existing conditions / lifestyle factors

3.5.1 Are there any relevant lifestyle factors e.g. diet, tobacco, alcohol abuse, etc.?

3.5.2 Are there any pre-existing medical conditions?3.5.3 Has the individual been declared medically fit to carry out his/her normal

duties in compliance with Company Standards?




3.5.4 Had the individual exhibited any signs, or symptoms associated with the cause of death before/during his/her recent work period?

3.5.5 Had the individual been recently referred to a Doctor?4. HEALTH MANAGEMENT ASPECTS

4.1 Organisation, roles and responsibilities

4.1.1 PDO & Contractor

4.1.2 What is known of the health management within the direct working environment of the deceased (health risk assessments, exposure monitoring, health controls and performance indicators.)

4.2 Health requirements for contract

4.3 HSE Plans (PDO & Contractor) (focus only on issues which are relevant to the cause of death)

4.4 Monitoring and Implementation of HSE Plans

4.4.1 PDO monitoring if PDO is fulfilling responsibilities and obligations

4.4.2 PDO monitoring if Contractor is fulfilling responsibilities and obligations

4.4.3 Contractor monitoring if it is fulfilling responsibilities and obligations

(above sections include monitoring, auditing, inspections, reviews etc.).

5. CONCLUSIONS

5.1 Primary and Contributory cause(s) of the Death

5.2 General conclusions or observations

6. RECOMMENDATIONS

6.1 Immediate actions

6.2 Follow-up actions

LIST OF ATTACHMENTS

- information such as autopsy report, medical fitness certificate, etc. if available)

- including action Close-Out form template

Appendix 3: General Medium Potential Incident Report

General Medium Potential Incident Report Form

REPORTING DEPARTMENT : DATE OF INCIDENT : / /

TIME OF INCIDENT :

INCIDENT LOCATION : CONTROLLED BY : [ ] PDO

[ ] CONTRACTOR




PDO INCIDENT SEVERITY (0, 1, 2, 3, 4 or 5) :

[ ]

[ ] INJURIOUS

[ ] OCC. ILLNESS

[ ] EQUIP. DAMAGE/OTHER

[ ] NEAR MISS

[ ] Potential Risk Rating

[ ] THIRD PARTY

ACTIVITY AT TIME OF INCIDENT

[ ] Using Portable Tools, Equipment

[ ] Welding / Burning

[ ] Manual Lifting / Handling

[ ] Cleaning

[ ] Operating Plant / Machinery

[ ] Digging

[ ] Handling Hazardous Materials

[ ] Sampling

[ ] Dismantling / Assembling

[ ] Draining / Flushing

[ ] Scaffolding

[ ] Disconnecting

[ ] Climbing / Descending

[ ] Connections

[ ] Walking at Same Level

[ ] Diving

[ ] Piloting

[ ] Other:

[ ] Working at High Level

BROAD TYPE OF INCIDENT

[ ] Loss of Containment [ ] Falling Objects

[ ] Fire and Explosion [ ] Electrical

[ ] Pollution Environment [ ] Assault

[ ] Air Transport [ ] Unsafe

Act/Condition

[ ] Sea Transport [ ] Lifting / Crane

Operations

[ ] Slips/Trips/Falls [ ] Other:

[ ] Theft & Sabotage

PARTIES INVOLVED

PDO DEPARTMENT / SECTION:

CONTRACTOR / SUB-CONTRACTOR:

THIRD PARTY (NAME):

PDO CUSTODIAN :

CONTRACT NUMBER:

TOTAL NUMBER INJURED [ ]




HOW THE INCIDENT OCCURRED (Attach sketch / photographs / Event Tree* as appropriate - more paper may be used if required).

Is the Activity and its associated Hazards / Controls adequately addressed in the applicable Safety Case(s) [Y/N}? :[ ]

If 'No', state measures proposed to rectify :

What actions were taken to determine if alcohol or drug use contributed to the Incident?

* Required for all High Potential Incidents

IMMEDIATE ACTION TAKEN TO PREVENT RECURRENCE

DETAILS OF INJURED PARTIES (to be completed by Medical Department)

INCLUDE:

NAME

DATE OF BIRTH

EMPLOYEE NO.

EMPLOYER

INJURY CLASS (if RWC state alternate work assigned)

NATURE OF INJURY / ILLNESS

PART OF BODY

EST. DATE FOR RETURN TO NORMAL WORK : / / (if LTI or RWC)

MEDICAL OFFICER : SIGNED : DATE : / /

Deemed fit to return to work on / / Signed: Medical Officer:

COST INCURRED AS A RESULT OF THIS INCIDENT (US$) :

PROPERTY DAMAGE: PRODUCT LOSSES :

ENVIRONMENTAL IMPACT : (YES/NO) [ ]

DESCRIPTION :




DETAILS OF EQUIPMENT DAMAGED

TYPE OF FACILITY : EQUIPMENT PART :

TYPE OF PLANT / EQUIPMENT : EQUIPMENT TAG NR :

PHASE OF OPERATION :

DETAILS OF LEAKING EQUIPMENT

LEAKING ITEM [ ] HAZARDOUS (Y/N) []

DURATION OF LEAK (MIN) [ ] INITIAL PRESSURE (KPa) [ ]

LEAK AREA (M2) [ ] LEAK STOPPED (AUTO / MANUAL) [ ]

FINAL PRESSURE (KPa) [ ] DID DETECTION SYS.OPERATE (Y/N)[ ]

REASON FOR DETECTION FAILURE :

FIRE / EXPLOSION

DURATION (MIN) [ ] EXTINGUISHED (AUTO / MANUAL) [ ]

EXTINGUISHING MEDIUM [ ] DID DETECTION OPERATE ? (Y/N) [ }

REASON FOR DETECTION FAILURE:




IMMEDIATE CAUSE

[ ] Information Error or Omission

[ ] Influence of intoxicating substances

[ ] Failure to follow rules / procedures;

[ ] Inadequate equipment / tools

specify :-

[ ] Misuse of equipment / tools

[ ] Procedure not documented

[ ] Work environment

[ ] Procedure considered impractical

[ ] Untidy Site (Poor housekeeping)

[ ] Procedure not communicated

[ ] Access

[ ] Other

[ ] External factors, 3rd party, weather

[ ] Inadequate warning, safety devices

[ ] Other:

[ ] Failure to observe / use warning safety devices

[ ] Lack of due care and attention

[ ] Improper manual handling

[ ] Attack by animal

[ ] Inadequate PPE

[ ] Fatigue / Stress

[ ] Failure to wear PPE

[ ] Lack of safety awareness

[ ] None of the above, specify:-

____________________________

UNDERLYING CAUSE

[ ] Inadequate physical / mental

capability

[ ] Inadequate knowledge / skill

[ ] Excessive stress

[ ] Improper motivation

[ ] Inadequate supervision

[ ] Inadequate policy, safety plan

[ ] Inadequate planning, organisation

[ ] Inadequate procedures, work

standards

[ ] Inadequate engineering design

[ ] Inadequate maintenance,

inspection

[ ] Other:_________________________________

ACTION TAKEN TO PREVENT RECURRENCE Further Recommendations are attached

ITEM

NO.

CORRECTIVE ACTION PDO ACTION PARTY

TARGET

DATE

STATUS




REPORT WRITER SUPERVISOR'S NAME : REF IND.:

SIGNED:

PDO INCIDENT OWNER'S NAME : REF. IND.:

SIGNED :

DATE REPORT COMPLETED : / /

RECOMMENDATIONS

DATE OF INCIDENT : / /

INCIDENT :

Number Description of Action Action Party Due by

SIGNED REPORT WRITER :

INCIDENT REVIEW COMMITTEE COMMENTS - APPEND TO REPORT ORIGINAL

DATE OF REVIEW : / / ARE THE DETAILS OF THE INCIDENT ADEQUATE FOR REVIEW (Y/N) : [ ]

REVIEW COMMITTEE COMMENTS :

SIGNED CHAIRMAN OF INCIDENT REVIEW COMMITTEE :




Guidance on the General Medium Potential Incident Report Form

The General Incident Report Form is used to report all types of Medium potential Incidents except Road Traffic Incidents.

Efforts must be made to provide all information requested. Draw a line through any section that is not applicable.

The General Incident Report Form is to be signed by the PDO supervisor responsible for completing the report, and the Incident Owner responsible for review and approval of the completed report.

The sections 'Details of Injured Parties' and 'Review Committee Comments' are not to be completed by the PDO supervisor. These sections are to be completed by the PDO Medical Department and the Secretary of the Incident Review Committee respectively. Routing is as prescribed on the Form's cover sheet.

Heading Details Required

Reporting Department State the Reference indicator for the PDO reporting department.

Incident Location State the general area followed by the specific locations e.g. Yibal/GGP etc.

Location Controlled by Tick PDO if is predominantly controlled by the Company (e.g. Production Station).

Tick Contractor if predominantly controlled by Contractor (e.g. Construction Site)

Tick Third Party if neither applies.

Activity at Time of Incident Tick the box against the action which had led directly to the occurrence of the Incident. This is not necessarily the action of the injured parties (if any). Refer to Appendix 4.4 for Definition of Activities.

Broad Type of Incident Tick the box against the general type of Incident. Refer to Appendix 4.5 for Definitions of Broad Incident Types.

Parties Involved Identify all parties involved that have or possibly have contributed to the Incident or have suffered from its consequences (injury/damage).

How the Incident Occurred Describe how the Incident occurred. This will be based on results from your investigation and must include:

- the reasons for carrying out the work

- events leading up to the Incident

- the Incident description and injury and/or

damage incurred.

State whether the Activity underway at the time of the Incident and

its associated hazards / controls are adequately addressed in the

applicable Safety Case(s). Does the Safety Case need updating?

The Report form may not provide enough space for the full

description. In this case, state that you have provided additional information (which may include photographs and drawings),and attach the material securely to the report form.




Immediate Action taken to prevent recurrence

State what has been done as an interim measure to prevent similar Incidents happening on the site or to personnel carrying out similar activities. The Action Parties must be listed against each preventative measure.




Details of Injured Parties

This section is to be completed and signed by the PDO Medical Department. The injury description is to be signed by the person who had provided the treatment. The following details are to be provided for all injured parties.


Name State full name

Date of Birth State date of Birth or age if unknown

PDO Reference indicator(employee)

State as applicable

Contractor State company name of contractor if applicable

Injury class FTL, PTD, PPD, LWC, RWC, MTC, FAC, OCC. Refer to Appendix 1 for definitions. IF RWC, STATE ALTERNATIVE WORK DUTIES ASSIGNED.

Nature of Injury State nature of injury. Only one entry is allowed. Refer to Appendix 4.9 for listing of injuries, and the rules in case of multiple injuries.

Part of body State part of body affected by main injury stated above.

Property Damage State the approximate costs (RO) of property damage incurred.

Product Losses, clean-up and restoration costs.

State the approximate cost of product losses including clean-up and restoration costs. Do not include cost of any deferred production.

Details of equipment damaged

Type of facility

Type of plant / equipment

Phase of operation

E.g. production stations, construction sites, etc.

E.g. compressor, manifold, laboratory

E.g. construction, commissioning, maintenance, operation.

Equipment part E.g. : flange, hose, gauge

Equipment Number State the equipment tag number

Details of leaking equipment

Leaking itemState the item of equipment from which the leak occurred e.g. Flange, valve, drain.

Duration of leak State duration in minutes.

Hazardous State yes/no depending on the pressure and nature of the fluids released.

Leak area State the cross-sectional area of leak (and not of the area affected)

Initial/final pressure State pressure in vessel prior to and after the leak occurred.

Did detection operate State yes/no

Leak stopped by State automatically or manually.

Fire/Explosion

Duration State duration in minutes.




Extinguished by State: Automatically, or manually. (Manually includes hand held extinguishers and fixed or portable systems which require manual activation).

Extinguishing medium E.g. Water, foam, CO2, BCF, powder

Did detection operate State yes/no

Reason for detection failure

Briefly describe reason if applicable

Immediate cause The immediate causes relate mainly to the actions of individuals directly involved in the Incident. Refer to Appendix 4.6 'Immediate Causes' for a description of the causes listed.

Underlying Causes The underlying causes can relate to managerial and organisational weaknesses which allowed the Incident to happen. Tick the appropriate boxes. Refer Appendix 4.7 'Underlying Causes'.

Action to prevent recurrence

Corrective Action items endorsed by the Incident Review Committee must be listed. Each item must be identified by a number for ease of follow-up. For each action item a PDO action party must be nominated by the Committee. Both the current status and the target completion dates must be recorded.

Review Committee Comments

This section to be completed by the Secretary of the appropriate Incident Review Committee following discussion at the meeting.


Date of review State the date on which the Incident was reviewed by the Incident Review Committee.

Details adequate State yes/no. If the report is inadequate it should be rejected and returned with comments to the relevant Incident Owner.

Comments State any comments by the review committee on the causes, circumstances and follow-up of the Incident, and the quality of the investigation and the report.

Appendix 4: Medium Potential Road Traffic Accident Report

REPORTING DEPARTMENT : DATE OF INCIDENT : / /

TIME OF INCIDENT : DAY OF THE WEEK:

INCIDENT LOCATION : CONTROLLED BY : [ ] PDO

[ ] CONTRACTOR




ACTUAL SEVERITY (0, 1, 2, 3, 4, 5) :

[ ]

[ ] INJURIOUS

[ ] OCC. ILLNESS

[ ] EQUIP. DAMAGE/OTHER

[ ] NEAR MISS

Potential risk Rating [ ]

[ ] THIRD PARTY

PARTIES INVOLVED

PDO DEPARTMENT / SECTION :

CONTRACTOR / SUB-CONTRACTOR :

THIRD PARTY (NAME) :

PDO CUSTODIAN :

INVOLVED ROP INSPECTOR NAME:

TOTAL NUMBER INJURED [ ]

HOW THE INCIDENT OCCURRED:




IMMEDIATE CAUSE

[ ] Information Error or Omission

[ ] Influence of intoxicating substances

[ ] Failure to follow rules / procedures;

[ ] Inadequate equipment / tools

specify :-

[ ] Misuse of equipment / tools

[ ] Procedure not documented

[ ] Work environment

[ ] Procedure considered impractical

[ ] Untidy Site (Poor housekeeping)

[ ] Procedure not communicated

[ ] Access [ ] Other

[ ] External factors, 3rd party, weather

[ ] Inadequate warning, safety devices

[ ] Other:

[ ] Failure to observe / use warning safety

devices

[ ] Lack of due care and attention

[ ] Improper manual handling

[ ] Attack by animal [ ] Inadequate PPE

[ ] Fatigue / Stress [ ] Failure to wear PPE

[ ] Lack of safety awareness

[ ] None of the above, specify:-

BROAD TYPE OF ACCIDENT

[ ] Single car Incident

[ ] Rollover [ ] Collision with: [ ] Pedestrian

[ ] Animal [ ] Object on the road [ ] Object beside the road

[ ] Other:

[ ] Two car Incident:

[ ] One vehicle stationary [ ] Both vehicles moving:

[ ] At junction: [ ] Roundabout [ ] X junction

[ ] Y junction [ ] T junction [ ] Not at a junction:

[ ] Moving along in same direction

[ ] Moving in opposite direction

[ ] Reversing [ ] Overtaking

[ ] Multiple car Incident, specify:

UNDERLYING CAUSE

[ ] Inadequate physical / mental

capability

[ ] Inadequate knowledge / skill

[ ] Excessive stress

[ ] Improper motivation

[ ] Inadequate supervision

[ ] Inadequate policy, safety plan

[ ] Inadequate planning,

organisation

[ ] Inadequate procedures, work

standards

[ ] Inadequate engineering design

[ ] Inadequate maintenance,

inspection

[ ] Other:_________________________________




GENERAL

Weather:

[ ] Clear

[ ] Rain

[ ] Fog

[ ] Dust

[ ] Overcast

CONDITIONS

Light:

[ ] Dawn

[ ] Daylight

[ ] Low Sun

[ ] Dusk

[ ] Dark

Road:

[ ] Straight

[ ] Bend

[ ] Incline

[ ] Incline & Bend

Quality:

[ ] Smooth

[ ] Stony

[ ] Corrugated

[ ] Loose

Condition:

[ ] Wet

[ ] Dry

[ ] Washouts

[ ] Heavy Sands

Shoulder:

[ ] Shoulder

[ ] Windrow

[ ] Profile Flat

[ ] Profile Up

[ ] Profile Down

SKETCH To show;

1. Direction of travel of all involved vehicles, pedestrians, etc.,

2. Point of impact ,

3. Final resting places,

4. Road measurements,

5. Any signposts,

6. Wind direction,

7. Sun position,

8. Skid marks and wheel tracks,

9. Windrows,

10. Road markings,

11. Distances to nearest town/camp,

12. Road gradients,

13 Each vehicle to be numbered for references in this form.

Refer to the Field supervisor's guide to road traffic Incident investigation




A copy of the page below has to be completed for each involved vehicle.

Vehicle number: (As indicated on previous page's sketch)

Vehicle type:

[ ] Motor cycle

[ ] Saloon

[ ] Station Wagon

[ ] Crewcab

[ ] Pick up

[ ] Light bus

[ ] Heavy bus

[ ] 2 axle truck

[ ] >2 axle truck

[ ] Articulated truck

[ ] Plant

Mode of operation:

[ ] 2 Wheel drive

[ ] 4 Wheel drive

[ ] Seat belts installed for all

[ ] Seat belts worn by all

Head lights

[ ] Off

[ ] City lights

[ ] Dipped

[ ] Full High Intensity rear

lights

[ ] Off

[ ] On

Vehicle condition:

[ ] Head lights

[ ] Rear lights

[ ] High intensity rear lights

[ ] Break lights

[ ] Signal lights

Tick if incorrectly functioning

Was the visibility obscured in

some way (e.g. dirty windscreen):

Tyre pressure:

[ ] Front left

[ ] Front right

[ ] Rear left

[ ] Rear right

[ ] Spare

[ ] Trailer tyres

Tick if within 20 KPa of

correct pressure.

VEHICLE SPECIFICATION AND INSPECTION

Licence Plate Number:

Date first registered:

Owned by:

Fleet number:

Make:

Estimate vehicle repair cost: OR

Estimate other direct cost: OR

Last vehicle inspection date:

(Attach vehicle inspection report)

Last date driver inspected vehicle:

If mechanical problems may have contributed to the Incident then the vehicle must be inspected by an expert. Contact TSL/4 who will arrange for the vehicle to be inspected by an expert..




DRIVER

Name: Date of birth:

Gender: Nationality: Occupation: Company/department: Company number: ROP driving licence:

Type(s): Number:

Expire date: PDO driving licence: Type(s): Number:

Expire date:

Date last eye test driver:

Driving experience in Oman: years

Driving experience in Interior: years

Date last attended tool box meeting:

Is driver on medication/ under the influence of alcohol/drugs:

Attended driving and road safety courses in last 3 years:

PASSENGERS

Names and Company/Dept.

1.

2.

3.

4.

LOAD

Composition:

Quantities:

Secured by:

Height to load from road surface:

Height load bed from road surface:

Quantity spilled/lost:

INJURIES

DRIVER

[ ] Head

[ ] Back

[ ] Neck

[ ] Hip

[ ] Leg

[ ] Foot

[ ] Abdomen

[ ] Chest

[ ] Arm

[ ] Hand

[ ] Multiple

INJURIES

PASSENGER1

[ ] Head

[ ] Back

[ ] Neck

[ ] Hip

[ ] Leg

[ ] Foot

[ ] Abdomen

[ ] Chest

[ ] Arm

[ ] Hand

[ ] Multiple

INJURIES

PASSENGER 2

[ ] Head

[ ] Back

[ ] Neck

[ ] Hip

[ ] Leg

[ ] Foot

[ ] Abdomen

[ ] Chest

[ ] Arm

[ ] Hand

[ ] Multiple

INJURIES

PASSENGER 3

[ ] Head

[ ] Back

[ ] Neck

[ ] Hip

[ ] Leg

[ ] Foot

[ ] Abdomen

[ ] Chest

[ ] Arm

[ ] Hand

[ ] Multiple

INJURIES

PASSENGER 4

[ ] Head

[ ] Back

[ ] Neck

[ ] Hip

[ ] Leg

[ ] Foot

[ ] Abdomen

[ ] Chest

[ ] Arm

[ ] Hand

[ ] Multiple




WORKING CONDITIONS DRIVER

Day before the Incident-

Hours worked: of which driving:

Slept at-

[ ] Home

[ ] Hotel

[ ] In vehicle

[ ] Outside

[ ] Elsewhere

Time of arrival at rest place/home:

Number of hours slept:

Day of the Incident-

Time of departure from home/rest place:

Prior to Incident-

Hours worked: of which driving:

Hours driven since last break:

Days worked since last full day without work:

Days to be worked until next full day without work:

Was the vehicle air-conditioned at the time of the Incident:

JOURNEY MANAGEMENT SYSTEM

Estimated Time of Departure: From:

Estimated Time of Arrival: At:

Journey approved by:

Other details of the Journey Management:

(Attach copy of Journey Management form)

THE ABOVE INDICATED INJURIES OF DRIVER(S) AND PASSENGERS ARE CONFIRMED BY THE UNDER SIGNED

MEDICAL OFFICER

NAME : REF. IND.:

SIGNED: --------------------------------

REMARKS:

DATE : / /

ACTION TAKEN TO PREVENT RECURRENCE Further Recommendations are attached

ITEM NO.

CORRECTIVE ACTION PDO ACTION

PARTY

TARGET DATE

STATUS




REPORT WRITER SUPERVISOR'S NAME : REF. IND.

SIGNED:

PDO INCIDENT OWNER'S NAME: : REF. IND.:

SIGNED :

DATE REPORT COMPLETED : / /

RECOMMENDATIONS

DATE OF INCIDENT : / /

INCIDENT :

Number Description of Action Action Party Due by

SIGNED REPORT WRITER :

INCIDENT REVIEW COMMITTEE COMMENTS - APPEND TO REPORT ORIGINAL

DATE OF REVIEW : / / ARE THE DETAILS OF THE INCIDENT ADEQUATE FOR REVIEW (Y/N) : [ ]

REVIEW COMMITTEE COMMENTS :

SIGNED CHAIRMAN OF INCIDENT REVIEW COMMITTEE :

Guidance on Medium Potential Road Traffic Accident Report Form




The Road Traffic Accident Report Form is used to report all types of Incident involving one or more moving vehicles.

Efforts must be made to provide all information requested. Draw a line through any section that is not applicable.

The Road Traffic Accident Report Form is to be signed by the PDO supervisor responsible for completing the report, and the Incident Owner responsible for review and approval of the completed report.

The section 'Review Committee Comments' is not to be completed by the PDO supervisor. This section is to be completed by the Secretary of the Incident Review Committee. Routing is as prescribed on the Form's cover sheet.


Reporting Department State the Reference indicator for the PDO reporting department.

Incident Location State the general area followed by the specific locations e.g. Yibal/GGP etc.

Location Controlled by Tick PDO if it is predominantly controlled by the Company (e.g. Production Station).

Tick Contractor if predominantly controlled by Contractor (e.g. Construction Site)

Tick Third Party if neither applies.

Parties Involved Identify all parties involved that have or possibly have contributed to the Incident or have suffered from its consequences (injury/damage).

How the Incident Occurred Describe how the Incident occurred. This will be based on results from your investigation and must include:

- events leading up to the Incident

- the Incident description and injury and/or

damage incurred.

The Report form may not provide enough space for the full

description. In this case, state that you have provided additional information (which may include photographs and drawings),and attach the material securely to the report form.

Immediate Cause Tick the applicable boxes. Refer to Appendix 4.6 'Immediate Causes' for a description of the causes listed.

Underlying Cause Tick the applicable boxes. Refer to Appendix 4.7 'Underlying Causes'.

Broad Type of Incident Tick the applicable boxes

General Conditions Tick the applicable boxes




Sketch To show:

1. Direction of travel of all involved vehicles, etc. 2. Point of impact

3. Final resting places

4. Road measurements

5. Any signposts

6. Wind direction

7. Sun position

8. Skid marks and wheel tracks

9. Windrows

10. Road markings

11. Distances to nearest town/camp

12. Road gradients

13. Number for all vehicles for reference

Vehicle type Tick the applicable boxes.

Mode of operation Tick the applicable boxes.

Vehicle condition Tick the applicable boxes.

Any obstruction of the visibility related to the vehicle; e.g. dirty windscreen, spare wheel blocking rear view etc., are to be specified.

Tyre pressure Tick the applicable boxes if tyre pressure is within 20 KPa (0.2 bar) of the required pressure.

Vehicle Vehicle specification and condition

Licence Plate Number Check details with ROP Motor Vehicle Licence

Date first registered See ROP Motor Vehicle Licence

Owned by See ROP Motor Vehicle Licence

Fleet number Applicable for vehicle used in the interior

Estimate vehicle repair cost

State the amount in OR required to bring the vehicle back in its original condition

Estimate other direct cost State cost for removing spills, vehicle replacement costs etc.

Last driver vehicle inspection date

Drivers are required to regularly carry out simple checks like tyre pressure. State the date of the last driver inspection.

Driver Driver, Passenger and Load

Name State full Name

Date of Birth State date of Birth or age if unknown

Gender Male or Female

Nationality As stated on the driving licence




Occupation As stated on the labour card

Company/department Company: As stated under Sponsor on the labour card. Department: for PDO staff only.

Company number Applicable for PDO and some contractors only.

ROP Driving Licence type Motor cycle, Light, Heavy Goods and/or Heavy Earth Moving Plant.

PDO Driving Licence type Complete as stated on the PDO driving licence.

Date last eye test Driver eye test is part of the procedure to obtain a driving licence, additional test may have been carried out after that time.

Date last attended tool box meeting

Tool box meetings are held to briefly discuss safety items before work commences

Is driver under medication/ under the influence of alcohol/drugs

Please specify the drivers' own statement in this respect.

Also specify if any testing for the presence of alcohol has been done.

Attended driving and road safety courses in the last 3 years

Courses like the Interior driving skill course may have been attended by the driver, please specify.

Passengers

Names State Full Names

Company/department Company: As stated under Sponsor on the labour card/department: for PDO staff only.

Load

Composition Specify the major components of the load carried by the vehicle

Quantity Specify quantities of major load components carried by the vehicle

Secured by Indicate which methods and tools were applied to secure the load

Height load from road surface

Give the height in meters of the top of the load with respect to road surface

Height load bed from road surface

Give the height in meters of the load bed with respect to the road surface

Quantity spilled/lost Specify the quantities of the major components of the load spilled or lost as a result of the Incident.

Injuries Driver Tick applicable boxes

Injuries Passengers Tick applicable boxes

Working Conditions Driver

DAY BEFORE ACCIDENT

Hours worked Specify number of hours worked and driving (including commuting)

Slept at Tick the applicable box (place of the last sleep period)

Time of arrival at rest place/home

Specify the time at which the driver arrived at his sleeping place after completing his work

Number of hours slept Specify number of hours slept by the driver based on his/her statement

DAY OF THE ACCIDENT




Time of departure from home/rest place

Specify the time the driver left for work.

Hours worked Specify number of hours worked and driving (including commuting)

Hours driven since last break

Specify number of hours driven since last break of at least 15 minutes.

Days worked since last full day without work.

Specify the number of the days since the last full day off from any of the drivers jobs (he/she may have more than one job)

Days to be worked until next full day without work.

Specify the number of the days to be worked until next full day off from any of the drivers jobs (he/she may have more than one job).

Was the car air-conditioned at the time of the Incident.

Specify if the car was equipped with an air conditioner and if it was switched on at the time of the Incident.

JOURNEY MANAGEMENT SYSTEMS

Estimated time of departure

Specify the estimated time of departure as included on the journey management form.

Estimated time of arrival Specify the estimated time of arrival as included on the journey management form.

Journey approved by Specify name of the person who signed the journey management form

Action to prevent recurrence

Corrective Action items endorsed by the Incident Review Committee must be listed. Each item must be identified by a number for ease of follow-up. For each action item a PDO action party must be nominated by the Committee. Both the current status and the target completion dates must be recorded.

Review Committee Comments

This section to be completed by the Secretary of the appropriate Incident Review Committee following discussion at the meeting.


Date of review State the date on which the Incident was reviewed by the Incident Review Committee.

Details adequate State yes/no. If the report is inadequate it should be rejected and returned with comments to the relevant Incident Owner.

Comments State any comments by the review committee on the causes, circumstances and follow-up of the Incident, and the quality of the investigation and the report.

Appendix 5: List of Activity at time of Incident






The PDO HSE Incident report form requires the actual activity at the time of the Incident to be noted. This appendix provides definitions of various activities.

Heading Description

Using portable tools and equipment

An Incident as a direct result of the use of hand tools and equipment including but not limited to the use of all powered or non-powered hand tools, e.g. screwdriver, wrench, shovel, grinder, chisel, hammer, punch, welding tools, saw, drill, blow torch, hatchet, pliers, scissors, etc.

Manual lifting/handling An Incident as a direct result of manually moving or rotating an object in any plane or direction.

Operating plant / machinery

An Incident as a direct result of operating a piece of equipment or machinery (excluding road traffic Incidents which are reported separately), including but not limited to pumps, compressors, mixers, well-heads, turbines, heat exchangers, boilers, draw-works, elevators, laboratory equipment, cranes, vehicle mounted hydraulic hoists, earth moving plant etc.

Handling hazardous materials

An Incident as a direct result of hazardous materials whether in solid, liquid or gas form, including but not limited to acids, alcohol's, arsenic compounds, pesticides, halogen compounds, nitrous fumes, petroleum products or gas, explosives, chemicals, drugs, medicines, radiation sources, etc. Check the Toxic Materials Manual for degrees of hazard.

Dismantling / assembling

An Incident as a direct result of assembling or dismantling of buildings, plants, process equipment, pumps, compressors, power generators, instruments, electrical equipment, etc.

Scaffolding An Incident as a direct result of the erection, dismantling or use of any type of scaffolding, including the use of fixed and movable ladders.

Climbing / descending An Incident as a direct result of climbing on, or descending from, any type of plant, building or process equipment.

Walking on same level An Incident as a direct result of any sort of walking (stopping, starting running, jumping) on any type of horizontal surface: floor, ramp, platform, walkway or street,

Driving / Piloting An Incident as a direct result of operating mobile equipment such as a car, truck, forklift, crane (whilst mobile) or piloting any sort of boat, plane or helicopter.

Working at high level An Incident as a direct result of working at a high (higher than waist) level above the surrounding grade level or water surface on platforms, columns, vessels, buildings, cranes, scaffolding, etc.

Welding / burning An Incident as a direct result of any welding, burning or flame cutting operation.

Cleaning An Incident as a direct result of any sort of internal or external cleaning operations of moving or stationary equipment, vessels, tanks, buildings, trucks, barges, etc.

Digging An Incident as a direct result of any kind of earth removal operations, be it onshore or offshore, in shafts or tunnels, by hand or with machines or explosives.

Sampling An Incident as a result of a sampling activity of any kind of solid, liquid or gas flow, e.g. feed stock flows, product flows, utilities system flows, etc.

Draining / flushing An Incident as a direct result of a draining / flushing operation of any kind of equipment, e.g. process vessels, tanks / tankers, pipes, bund-wall areas, sewer systems, etc.

Disconnecting connections

An Incident as a direct result of a part of system, e.g. disconnecting of instrument or electrical cables or plugs, disconnecting of temporary or permanent pipes or hoses, disconnecting of wire running tools from wellhead, etc.

Diving An Incident as a direct result of any operation where people are required to work fully submerged in water, with or without aqualung, umbilical or submarine hoses, including all surface operations, e.g. compression and decompression facilities.

Other activity An Incident not resulting from any of the other mentioned activities, excluding a road traffic Incidents which is reported on a separate form. In this case the supervisor should state the ‘Other’ activity.


Appendix 6: Definitions of Incident Types

The broad Incident types fall into several main categories which are not mutually exclusive. Only one entry per Incident can be entered, determined by which type of Incident caused the major injury, environmental or financial impact.

Event Description

Air Transport An Incident which happens while transporting people or goods by air (plane, helicopter) and an Incident of which the major impact is limited to loss of or damage to aircraft and injury and/or loss of life of crew and passengers. (For example, an aircraft which crashes into a production station causes loss of containment in a process vessel and subsequently a fire which destroys the complete facility. This Incident will be classified as a fire and explosion not as air transport).

Assault An Incident of which the major impact is caused by the direct consequences of an assault on any person or installation.

Electrical An Incident of which the major impact is caused by an electrical phenomenon, short circuit, static electrical discharge, electrocution, etc., and where this impact is limited to the direct consequences of the electrical phenomenon.

Falls & Trips An Incident of which the major impact is caused by a fall, trip or slip and where this impact remained limited to the direct consequences of the fall, trip or slip.

Falling objects An Incident of which the major impact is caused by a falling object and this impact is limited to the direct consequences of the falling object.

Fire and explosion

An Incident of which major impact is a direct result of a fire and/or explosion.

Lifting / Crane operations

An Incident of which the major impact is caused by the direct consequence of lifting or crane operations.

Loss of Containment

An Incident of which the major impact is a direct result of loss of containment of a fluid, e.g. oil, gas, chemical, water, etc. The loss of containment can be due to a leak, rupture, blowout, a malfunctioning valve, etc.

Pollution / environment

An Incident of which the major impact is pollution or any other damage to the environment, e.g. water, soil, air or plant/animal life.

Road Transport Any Incident involving a moving vehicle

Theft and Sabotage

a non-HSE Incident, which:

- was deliberately initiated for the purpose of secretly taking or damaging property belonging to someone else with the intention of permanently depriving the owner of its use or possession, and

- where the most severe impact is the loss or damage of assets, including information assets.

Theft may involve visible intrusion (eg. burglaries) or simply disappearance of an asset.

Unsafe acts / conditions

An Incident without any injury, environmental or financial impact, which could, however, have developed into an Incident with injury, environmental or financial impact because of unsafe acts or conditions observed or violation of commonly accepted safe procedures.

Water transport An Incident which happens while transporting goods or people by sea (e.g. boat, barge,) and an Incident of which the major impact is limited to loss of or damage to the ships/barges and their cargo and injury and/or loss of life crew and passengers. (For example, a super tanker loses its cargo of 200,000 bbl oil in coastal waters causing damage to shore and wildlife will be classified as pollution/environmental).




Other Any other Incident which can not be categorised within the other broad Incidents type. Including for example, an illness or adverse health effect caused by recurrent exposure to hazards. The supervisor should state the "Other" Broad Incident type.

Appendix 7: List of Immediate Causes

Heading Description

Information error or omission

Was an information error or omission occurring between parties directly or indirectly involved with the activities leading to the Incident a contributing factor?

Failure to follow rules/procedures

Was failure to follow established rules and procedures a contributing factor, e.g. permit-to-work system not followed, gas testing or vessel entry procedures not followed, etc.? There are several reasons why there may be a failure to follow established procedures. These are listed below :-

: Procedure not documented. Were there any documented rules or procedures which adequately covered the task or activity being done when the Incident occurred?

: Procedure considered impractical. Were the rules and procedures covering the task or activity in place but generally not enforced because they were recognised or considered to be impractical / inappropriate for the circumstances ?

: Procedure not communicated. Were practical rules and procedures covering the task or activity in place but they had not been successfully communicated to the people involved in the Incident? A lack of communication may be due to the persons being unaware of the procedure or being unable to understand it.

: Other - any other reason not covered above why known rules and procedure were not followed.

Inadequate warning/safety devices

Were inadequate warning signs, lights, horns, whistles, etc., or malfunctioning warning signals a contributing factor. Or were safety devices, such a relief valves, blowdown system, level, pressure, gas or fire detectors, guards, screens or safety nets, by-passed, disconnected, maladjusted, incorrectly replaced or not installed a contributory factor?

Failure to observe / use warning safety devices

Were available warning safety devices ignored, or were necessary warning signals not installed, placed or used?

Improper manual handling

Was improper handling e.g. incorrect lifting, carrying, gripping, applying of force a contributory factor?

Inadequate PPE Was inadequate quality of required personal protective equipment a contributory factor?

Failure to wear PPE

Was the failure to wear required PPE equipment a contributory factor?

Influence of intoxicating substances

Were the effects, including side effects, of intoxicating liquids or illegal drugs a contributory factor?

Inadequate equipment/tools

Were the quality or quantity of the equipment or tools a contributory factor. e.g. non sparking tools, uninsulated electrical tools, no flame or spark arresters, etc.? Did the equipment or tools fail during operation?




Misuse of equipment/tools

Was improper use of tools or equipment a contributory factor? Work environment Was excessive noise, inadequate ventilation, inadequate illumination, inadequate traffic control, inadequate building or workshop layout; inadequate furniture, etc. a contributory factor?

Work Environment Was excessive noise, inadequate ventilation, inadequate illumination, inadequate traffic control, inadequate building or workshop layout, inadequate furniture, etc. a contributing factor?

Untidy site Was untidy worksite a contributing factor?

Access Was inadequate or congested access, aisle space, exits or clearance a contributory factor?

External factors (third party, weather)

Were uncontrollable outside influences factors, such as third party drivers, environmental conditions, sabotage, war, weather, floods, landslides, etc., a contributory factor?

Other State any "Other" Immediate Cause as: Lack of due care and attention; Attack by animal; Fatigue / Stress; or Lack of safety awareness. If none of these are applicable then specify applicable immediate cause in words.

Appendix 8: List of Underlying Causes

Note these Underlying Causes are defined in slightly different terms than the Tripod Beta General Failure Types. If a Tripod Beta analysis is used then the Tripod Beta GFTs shall be stated.

Heading Description

Inadequate Physical / Mental Capability Was some person's lack of physical (eyesight, cripple, hernia, fitness, etc.) or mental capability or the lack of aptitude for the job a factor?

Inadequate Knowledge / Skill Was the lack of knowledge on how to perform the task safely a factor, or was the lack of skill to do the job safely a factor?

Excessive Stress Was physical or mental stress a factor in the Incident?

Improper Motivation Was motivation to perform improper activities or to perform critical activities a factor? Were any of the persons involved distracted, reckless or uninterested?

Inadequate Supervision Was inadequate leadership in direct Line supervision or inadequate leadership of safety programme activities a factor?

Inadequate Policy, Safety Plan or communication thereof.

Was an inadequate formulation of the Policy statement a factor, or was an inadequate safety plan a factor?

Inadequate Planning and Organisation Was inadequate job planning or preparation a factor, or was an inadequate organisational structure (manpower, communication) a factor?

Inadequate Procedures, Work Standards or communication thereof

Were inadequate methods, procedures, practices or rules a factor?

Failure to Observe / Use Warning / Safety Devices

Were available warning safety devices ignored, or were necessary warning signals not installed, placed or used?

Inadequate Engineering / Design Was inadequate design / specification of the facility or of the process line equipment or of safety devices a factor? Or was inadequate construction or inspection of construction a factor?




Inadequate Maintenance / Inspection Was premature failure or malfunction of equipment or structures a factor? Or was insufficient (or lack of) preventive maintenance or periodic inspection programme a factor?

Other Underlying Causes Those which can not be categorised within the above-mentioned underlying causes.

Appendix 9: List of Facilities / Plant / Equipment

Type of Facility Phase of Operation Material/Product

Process and treatment plants Construction or erection Additive

Production facilities Dismantling Bitumen

Utilities Maintenance or repair Chemical (general)

Product storage (tank farms) Gas-freeing or cleaning of equipment Chlorine

Pipe s (off-plot) Starting up Crude oil

Transport facilities Shutting down Fuel gas

Construction sites Upset conditions Fuel oil

Berths/jetties Normal operation Gasoline

Movable Field Installations Others Natural gas

Loading/unloading facilities H2S

Buildings Source of Ignition Hydrocarbons

Others Auto or spontaneous ignition Kerosene

Hot surfaces or equipment LPG

Equipment Involved Welding brazing cutting Residue

Columns Flares Steam

Compressors Open flames Sulphur dioxide

Furnaces incl. boilers Smoking Water

Gas turbines Lighting Others

Generators Static electricity

Heat exchangers Friction-overheating or impact sparks

Pipework Smoldering lagging or waste Leaking Item

Pumps Gasoline /diesel engine or exhaust Gasket

Reactors Electrical equipment Fitting

Tanks Collision, vehicles etc. Flange

Vessels Sabotage or vandalism Vent

Others Chemical reaction Valve

Plug

Part of Equipment Iron Sulphide oxidation Hose




Bellows Others Seal

Burners Pipe

Filter Unit or Plant Drain

Flange/gasket Control building Nipple

Hose Offices Pinhole

Instrument element Laboratories Weld

Loading arm Living quarters/houses Other

Pump body Restaurant

Pump seal Warehouse/yard

Safety relief valve Workshop/garages

Small bore piping Steam/Hot water injection

Valve- Firewater system

Others Flow line-gas \ oil

Gas Compression

Gas Treatment

Gathering Station

LPG Facilities

Oil Separation

Oil storage

Offshore mooring

Pipeline Gas \ Oil \ other

Pumping \Booster Station

Station \ metering

Tanker- sea

Tanker Loading

Well Head/Drilling facilities

Wireline/workover unit

Others

Appendix 10: List of Injury / Occupational Illness

(Note: Only one entry is permissible)

Heading Description

Nature of injury The nature of injury classification identifies the injury in terms of its principal physical characteristics.

General rule Name the basic injury rather than its sequel.




Rules for selection in cases of multiples injures

When one injury is obviously more severe than any of others, select that injury. For example select an injury involving permanent in preference to temporary injury.

When there are several injuries of different natures, such as cuts and sprains, no one is indicated as being more serious than the others, classify as multiple injuries.

Damage of eyeglasses, hearing aids, dentures or artificial body parts is not considered an injury.

Open wounds e.g. cuts, lacerations, punctures, foreign objects (splinter).

Crushing/contusions/bruises

Intact skin surface.

Bites and stings All bites and stings (insect, dog, human, reptile, etc.) except venomous reptile and insect bites, see poisoning.

Superficial injuries e.g. scratches, abrasions.

Burns (heat/cold) The effect of contact with hot or cold substances. Include electric burns, but not electric shock. Does not include chemical burns, effects of radiation, sunburn, systematic disability such as heat stroke, friction burns, etc.

Burns (chemical) Tissue damage resulting from the corrosive action of chemicals, chemical compounds, fumes etc. (e.g. acids, alkalis).

Heat stroke/sun stroke/heat exhaustion

All effects of exposure to environmental heat. Does not include sunburn or other effects of radiation.

Radiation effects Sunburn and all forms of damage to tissue, bones or body fluids produced by exposure to radiation (e.g. sun light, X-ray, gamma ray, etc.).

Asphyxia, strangulation Respiratory problems caused by oxygen deficiency or by airway obstruction. Does not include drowning or the effects of toxic agents.

Fractures A break or rupture in a bone.

Cerebral Concussion Transient loss of consciousness for a few seconds followed by a retrograde and post-traumatic amnesia

Cerebral Contusion Loss of consciousness longer than cerebral concussion often followed by a severe residual neurologic deficit.

Dislocation Displacement of a bone end at a joint

Drowning Aspiration of fluids which results directly in asphyxia.

Sprains and strains A sprain is an injury with stretched or torn ligaments, soft tissue damage around the joint. A strain is a muscle injury from over stretching.

Hernia/rupture Includes both inguinal and non-inguinal hernia, and all internal injuries.

Drowning

Loss of sight Loss of sight or impairment of sight.

Hearing loss or impairment

Hearing loss / impairment as a separate, single injury not the sequel of another injury.

Poisoning A systematic morbid condition resulting from the inhalation, ingestion, or skin absorption of toxic substance affecting the functioning of the metabolic system, the nervous system, the circulatory system, the digestive system, the respiratory system, the excretory system, the musculo-skeletal system, etc. Includes chemical or drug poisoning, metal poisoning, organic diseases, and venomous reptile and insect bites. Does not include effects of radiation, pneumoconiosis (dust disease), corrosive effects of chemicals; skin surface irritations; septicemia or infected wounds.




Other injury All injuries not elsewhere identified (state ).

Multiple injuries Several injuries of different natures, such as cuts and sprains, no one of which is indicated as being more serious than the others.

Electrical shock Shock from contact with an electrical source. Excludes electric burns.

Nature of Occupational Illness

Occupational illness exclude all illness caused by a single event or a number of events close together in the course of employment. Only one entry is allowed.

Heading Description

Noise Induced Hearing Loss Hearing loss from long-term exposure to high noise levels.

Lung problems/diseases e.g. occupational asthma, dust disease (pneumoconiosis) such as silicosis or asbestosis.

Skin disease e.g. contact dermatitis from repeated skin contact with solvents or allergic eczema from repeated contact with epoxy resins.

Poisoning Systemic affects due to toxic mass e.g. anemia from repeated benzene exposure.

Physical causes e.g. radiation, excluding effects from a single event, diseases from long-term exposure to vibration. (Excludes Noise Induced Hearing Loss and toxic materials).

Infections/contagious e.g. tropical infections or contagious disease contracted during the course of employment, animal disease, tuberculosis.

Cancer e.g. mesothelioma from asbestos exposure.

Stress Disorders due to stress at work

Repetitious Injury Disorders associated with repeated minor trauma.

Other occupational illness (state).

Any illness not listed above - specify details

Classification of Occupational Illness

1 Infectious and Parasitic Diseases: malaria, food poisoning, infectious hepatitis, dysentery, lambliasis, legionnaire's disease.

2 Skin Diseases and Disorders: contact dermatitis, allergic dermatitis, rash caused by primary irritants and sensitisers or poisonous plants, oil acne, chrome ulcers, chemical burns or inflammations.

3 Respiratory Conditions due to Dust or Toxic Agents: silicosis, asbestosis, pneumoconiosis, pneumonitis, (allergic) bronchitis, alveolitis, asthma, pharyngitis, rhinitis or acute congestion due to chemicals, dusts, gases, or fumes.

4 Poisoning (Systemic Effects of Toxic Materials): poisoning by lead, mercury, arsenic, cadmium, or other metals; poisoning by carbon monoxide, hydrogen sulphide, or other gases; poisoning by solvents; poisoning by pesticides; poisoning by other chemicals such as formaldehyde, plastics and resins.

5 Disorders due To Physical Agents (Other than Noise and Toxic Materials)Examples: heat-stroke, sunstroke, heat exhaustion and other effects of heat stress; freezing, frostbite and other effects of exposure to low temperatures; caisson disease; effects of ionising (alpha, beta and gamma rays, radium) and non-ionising (welding flash, ultraviolet rays, microwaves, sunburn) radiation

6 Disorders associated with Repeated Trauma: synovitis, tenosynovitis, and bursitis; Raynaud's phenomenon; other disorders of the musculo-skeletal system and connective tissue associated with repeated trauma.




7 Cancers and Malignant Blood Diseases: mesothelioma; bladder cancer; leukaemia and other malignant diseases of blood and blood forming organs

8 Disorders due to Mental Stress: tension headache, depression, neurosis, "stress", functional disorders of the gastrointestinal tract

9 Noise Induced Hearing Loss: definition and criteria for reporting are given in the SHC Noise Guide 1991.

10 Other Illness and Disorders: Benign tumours; eye conditions due to dust and toxic agents; other (non-malignant) diseases of blood and blood forming organs.

Appendix 11: Examples Determining Environmental Incident Risk Potential

11.1 Incidental Releases of Solids or Liquids to Soil or Water

The Environmental Incident Severity Rating Index (EISRI) has been developed to give a quantitative assessment of the potential of a solid or liquid released to soil or water to damage the environment.

There are three main factors which determine the potential for a particular environmental Incident to impact the environment:

Sensitivity Index (S) - the sensitivity of the receiving environment into which the material is released which depends upon various factors:

Proximity to people either as local residents, workers in a work location or temporary accommodation, or travelling;

proximity to "domestic" (i.e. herded or grazing) animals or agriculture;

Proximity to native (i.e. wild) fauna and flora, and their types;

Proximity and ease of access to surface water and potable aquifers;

Local topography, land use and land/soil quality.

These factors have been summarised and a Sensitivity Index (S) allocated as shown in the table below.

Table Appendix-11.1-Sensitivity Index

Description of Receiving Environment Sensitivity Index (S)

Flat topography (no vegetation, no population) 1

Sloping topography (no vegetation, no population)

5

Proximity to aquifer for use other than drinking water

10

Marine (sea) environment 100

Agricultural land, populated 100

Proximity to potable aquifer 100

Wadi 100

Within a Nature Reserve 100

Toxicity Index (T) - a measure of the toxicity of the material (solid or liquid) released into the environment. The Toxicity Index for several materials commonly used in PDO's operations is given in Table Append-11.2. or can be obtained from the corresponding SHOC card of the chemical concerned

Quantity (Q) - the amount of material released expressed in cubic metres.




Note that all spills or leaks are reportable (within the general rules found in Section 11.1) no matter how small the quantity is.

The EISRI is calculated as follows:

EISRI = (S x T x Q) = S x T x Q ÷ 1,000

1000

The calculated EISRI value is then entered into Table Append-11.3 to determine the actual environmental impact and severity rating.

The potential environmental risk depends on the potential severity and the probability of the Incident happening again. Potential severity is determined by recalculating the value of EISRI based on potential scenarios and using Table Append-11.3. Once the potential severity has been determined, the probability of the Incident happening again must be assessed. Both are then entered into the RAM to determine the overall potential HSE risk.

Table Append-11.2 Toxicity Index of Common Hazards

Common Hazards Discharged in an Environmental Incident

Waste Management Chart Number

(Part D of the Waste Management Manual)

Toxicity Index

Acid spent A001 1,000

API sludge O003 1,000

Asbestos A004 1,000

Battery acid B004 1,000

Chemical waste C005 10,000

Clinical waste C006 1,000

Crude oil Refer to L001 1,000

Cuttings (oil base mud) C007 1,000

Cuttings (water base mud) C008 10

Degreasing solvents (halogens) D001 1,000

Dehydration water P007 10

Drilling fluid (oil based) O001 1,000

Drilling fluid (brine) B005 10

Engine oil (spent) L001 1,000

Ferric sulphide (pyrophoric dust) P008 10,000

Low Specific Activity Scale (or NORM)) N001 10,000

Lubricants (spent) L001 1,000

Paint P002 100

Paint thinner T002 100

Pigging wastes P004 100

Sewage (untreated) S001 100

*




Table Append-11.3 Severity Rating and Qualitative Environmental Impact

Calculated EISRI Environmental Impact

Severity Rating

0 No Effect 0

< 50 Slight Effect 1

50 - 4,999 Minor Effect 2

5,000 - 49,999 Localised Effect 3

50,000 - 499,999 Major Effect 4

> 500,000 Massive Effect 5

11.2 Other Environmental Incident Types

Some environmental Incidents can not easily be classified according to quantity, toxicity and sensitivity of the receiving environment and hence the EISRI can not be determined quantitatively. Examples of these Incidents types include animals (camels, desert fox, rabbits, etc) falling into waste pits, releases of natural gas, Halons or CFCs, presence of objectionable smells or high noise levels, and third party environmental complaints, etc. For these types of environmental Incidents, a qualitative approach for determining the environmental impact must be used as defined in Table Appen-11.4. Table Append-2.4 contains a qualitative description of each environmental impact and corresponding severity rating.

11.3 Examples Of Environmental Incident Risk Assessment

11.3.1 Oil spill

Example 1

Consider a spill of 1 m3 of oil from a flow line in flat, unpopulated terrain. As the Incident is a spill of liquid an EISRI can be calculated. Using Table Append-11.1, the Sensitivity Index (S) for flat unpopulated terrain is 1. Using Table Append-11.2, the Toxicity Index (T) for oil is 1,000. The quantity (Q) of oil released is 1 m3.

Therefore the EISRI = S x T x Q/1000 = 1 x 1,000 x 1/1000 = 1. Using Table Appendix-11.3, the actual consequence of the Incident is a Slight environmental impact with a severity rating of 1. An actual severity of 1 indicates that investigation may be delegated to the level of Company Site Representative.

In calculating the Potential Consequence of the Incident it is necessary to review what could potentially have happened to increase the severity of the Incident. For example, consider whether the flow line runs through a wadi anywhere along its length. In this case the Sensitivity Index would increase to 100 and the EISRI to 100. Using Table Appendix-11.3, the Potential Consequence of the Incident becomes Minor environmental impact with a severity rating of 2. Also consider whether the volume of oil spilled




could have been larger. For example the leak could have started just before nightfall and would not be noticed until the morning, increasing the volume to 100 m3. This could further increase the EISRI to 10,000. Using Table Appendix-11.3, the Potential Consequence of the Incident becomes Localised environmental impact with a severity rating of 3. If the probability of the Incident happening again is determined to be 'D' (i.e. happens more than 5 times a year in PDO), the potential HSE risk in RAM is 3D and the Incident is classified as Medium Potential.

Example 2

Consider a 5 m3 crude oil leak into the sea while loading at the SBM. As the Incident is a spill of liquid an EISRI can be calculated. Using Table Appendix-11.1, the Sensitivity Index (S) for the sea is 100. Using Table Appendix-11.2, the Toxicity Index (T) for oil is 1,000. The quantity (Q) of oil released is 5 m3.

Therefore the EISRI = S x T x Q/1000 = 100 x 1,000 x5/1000 = 500. Using Table Appendix-11.3, the actual consequence of the Incident is a Minor Environmental Impact with a severity rating of 2. An actual severity of 2 indicates that investigation may be delegated to the level of Company Representative.

In calculating the Potential Consequence of the Incident it is necessary to review what could potentially have happened to increase the severity of the Incident. For example, consider whether the volume of oil spilled could have been larger. For example 50 m3 of oil could have been spilled before action was taken to stop the flow. This would increase the EISRI to 5,000. Using Table Appendix-2.3, the Potential Consequence of the Incident becomes Localised environmental impact with a severity rating of 3. If the probability of the Incident happening again is determined to be 'D' (i.e. happens more than 5 times a year in PDO), the potential HSE risk in Fig. RAM is 3D and the Incident is classified as Medium Potential.

Alternatively, if the potential quantity spilled is 500 m3, the EISRI would increase to 50,000. Using Table Appendix-2.3, the Potential Consequence of the Incident becomes Major environmental impact with a severity rating of 4. If the probability of the Incident happening again is determined to be 'D' (i.e. happens more than 5 times a year in PDO), the potential HSE risk in RAM is 4D and the Incident is classified as High Potential. Using Fig. G4 the ownership level is Line Director.

11.3.2 Natural Gas Leak

Consider a 2 scm gas leak from a flow line. As the Incident does not involve a spill of liquid or solid material, a qualitative approach for determining environmental impact must be used. Using the qualitative description of Environmental Impact of an Incident in Table Appendix-11.4, the actual consequence of the Incident is a Slight environmental impact with a severity of 1 since the quantity of natural gas released is less than 1,000 scm. An actual severity of 1 indicates that investigation may be delegated to the level of Company Site Representative.

In calculating the Potential Consequence of the Incident it is necessary to review what could potentially have happened to increase the severity of the Incident. For example, consider whether the leak could have gone undetected for longer resulting in a larger volume of gas, say 1,500 scm, being released. In this case, using Table Appendix-11.4, the Potential Consequence of the Incident becomes Minor environmental impact with a severity rating of 2. If the probability of the Incident happening again is determined to be 'D' (i.e. happens more than 5 times a year in PDO), the potential HSE risk in RAM is 2D and the Incident is classified as Medium Potential.

11.3.3 Halon Release

Consider a release of 75 kg of Halon. As the Incident does not involve a spill of liquid or solid material, a qualitative approach for determining environmental impact must be used. Using the qualitative description of Environmental Impact of an Incident in Table Appendix-11.4, the actual consequence of the Incident is a Minor environmental impact with a severity rating of 2 since the quantity of Halon




released lies between 50 and 100 kg. An actual severity of 2 indicates that investigation may be delegated to the level of Company Representative.

In calculating the Potential Consequence of the Incident it is necessary to review what could potentially have happened to increase the severity of the Incident. Usually if the fire fighting system is triggered, all the Halon contained in the system is released at once and there is no potential for the amount released to be increased. In the unlikely event, for example, of only half the total quantity of Halon being released, the quantity could increase to 150 kg. In this case, using Table Appendix-11.4, the Potential Consequence of the Incident becomes Localised environmental impact with a severity rating of 3. If the probability of the Incident happening again is determined to be 'D' (i.e. Halon releases occur more than 5 times a year in PDO), the potential HSE risk in RAM is 3D and the Incident is classified as Medium Potential.

11.3.4 Untreated Sewage Release

Consider a spill of 20 m3 of untreated sewage from a tanker on the road between a seismic camp and a sewage treatment plant. As the Incident is a spill of liquid an EISRI can be calculated. The road is running through flat, unpopulated terrain. Using Table Appendix-11.1, the Sensitivity Index (S) for flat unpopulated terrain is 1. Using Table Appendix-11.2, the Toxicity Index (T) for untreated sewage is 100. The quantity (Q) of sewage released is 20 m3.

Therefore the EISRI = S x T x Q/1000 = 1 x 100 x20/1000 = 2. Using Table Appendix-11.3, the actual consequence of the Incident is a Slight Environmental Impact with a severity rating of 1. An actual severity of 1 indicates that investigation may be delegated to the level of Company Site Representative.

In calculating the Potential Consequence of the Incident it is necessary to review what could potentially have happened to increase the severity of the Incident. For example, consider whether the road runs through a populated area anywhere along its length. In this case the Sensitivity Index would increase to 100 and the EISRI to 200. Using Table Appendix-11.3, the Potential Consequence of the Incident becomes Minor environmental impact with a severity rating of 2. If the probability of the Incident happening again is determined to be 'C' (i.e. Incident has occurred in PDO), the potential HSE risk in RAM is 2C and the Incident is classified as Low Potential.

11.3.5 Dead Wildlife in Drilling Waste Pit

Consider a camel found dead in a drilling waste pit with complaints or claims received from the public. As the Incident does not involve a spill of liquid or solid material, a qualitative approach for determining environmental impact must be used. Using the qualitative description of environmental impact of an Incident in Table Appendix-11.4, the actual consequence of the Incident is a Minor environmental impact with a severity rating of 3. An actual severity of 3 indicates that investigation may be delegated to the level of Section Head.

In this example, it is difficult to predict a situation where the Potential Consequence of the Incident is higher than the Actual Consequence and therefore the Potential Consequence equals the Actual Consequence. If the probability of the Incident happening again is determined to be 'C' (i.e. Incident has occurred in PDO), the potential HSE risk in RAM is 3C and the Incident is classified as Medium Potential.

11.3.6 Persistent Complaints from Third Parties

Consider a number of complaints being received from third parties owing to odours from a sewage treatment plant. As the Incident does not involve a spill of liquid or solid material, a qualitative




approach for determining environmental impact must be used. Using the qualitative description of Potential Consequence of an Incident in Table Appendix-11.4, the actual consequence of the Incident is a Localised environmental impact with a severity rating of 3. An actual severity of 3 indicates that investigation may be delegated to the level of Section Head.

In this example, it is difficult to predict a situation where the Potential Consequence of the Incident is higher than the Actual Consequence and therefore the Potential Consequence equals the Actual Consequence. If the probability of the Incident happening again is determined to be 'E' (i.e. complaints are made more than 5 times a year for the particular location), the potential HSE risk in RAM is 3E and the Incident is classified as High Potential.

11.7 Persistent Cases of ExceedingEnvironmental Permit Requirements

Consider a sewage treatment plant where more than three consecutive weekly analytical results indicate that the total coliform count is > 1600 (MPN/100ml). Since the permit requirement is 1,000 (MPN/100ml), this is a regular case of exceeding the limits. As the Incident does not involve a spill of liquid or solid material, a qualitative approach for determining environmental impact must be used. Using the qualitative description of Potential Consequence of an Incident in Table Appendix-11.4, the actual consequence of the Incident is a Localised Environmental Impact with a severity rating of 3. An actual severity of 3 indicates that investigation may be delegated to the level of Section Head.

In this example, it is difficult to predict a situation where the Potential Consequence of the Incident is higher than the Actual Consequence and therefore the Potential Consequence equals the Actual Consequence. If the probability of the Incident happening again is determined to be 'E' (i.e. exceeding permit requirements occurs more than 5 times a year at the particular location), the potential HSE risk in RAM is 3E and the Incident is classified as High Potential. Incident ownership level is Line Director.

Table Appendix 11.4 Potential Environmental Impact

Severity Rating


Description

1. Slight Effect An adverse effect on any attribute1 of the environment is observable or measurable above background, is of short duration, confined to the Company site and no complaints from third parties or governmental concern. Halon and CFC release < 50 kg. Gas leak < 1,000 scm. Remedial action cost less than US$ 1,000. EISRI < 50.

Examples:

Small oil/water spill from flow line confined to soil surface and disappears after evaporation.

Wild or domestic animal found in waste pit and rehabilitated.

1 Visual quality; Chemical quality (air, soil, water, living resources); Biological quality (diversity); Noise level; Smell




2. Minor Effect Adverse effect is likely to be detected by third parties but does not exceed a recognised standard of environmental quality. Effect does not impair the use of the environment for other users. Single case of exceeding permit requirement or internally prescribed standard. Halon and CFC release 50 - 100 kg. Gas leak of 1,000 scm and greater. Investigation, monitoring or clean-up cost US$ 1,000 - 10,000. EISRI 50 - 4,999.

Examples:

Oil/water spill from flow line which seeps into the sand.

Gas or exhaust release causing temporary smoke or smell.

Improperly disposed non-hazardous waste which is readily collected.

Wild or domestic animal found dead in waste pit.




Severity Rating


Description

3. Localised Effect

Environmental quality in the vicinity of operations becomes substandard or unfit over a limited area for one or more purposes including supporting normal wildlife population; interference with other users causes loss of earnings, complaints or claims. Repeated cases of exceeding permit requirement or internally prescribed standard. Halon and CFC release > 100 kg Remedial action cost US$ 10,000 - 100,000. EISRI 5,000 - 49,999.

Examples:

Oil spill from flow line which seeps into sand or from pipeline requiring significant excavation.

Localised contamination of 3rd party land or soil by oil, spilled chemical or waste, preventing use of an individual source of potable water or piece of land.

Physical damage which results in loss of livestock or interference with overland travel.

Repeated occurrence of objectionable smells which result in complaints from 3rd parties.

Improper disposal of hazardous waste requiring identification, analysis and site clean up.

Excessive oil levels in permitted MAF tank farm discharge or oily sheen observed.

Small oil spill at MAF tanker loading operation which has to be cleaned up from sea.

Physical damage to natural features (ecological, heritage, surface geology).

Significant deviation from environmental permit (e.g. sewage treatment effluent quality).

A number of wild animals found dead in waste pit.

A radioactive source lost subsurface.

4. Major Effect Environmental damage is widespread and detectable for some distance beyond operational area. Large scale effort is required to restore the environment to a satisfactory condition. Clean-up and site restoration costs US$ 100,000 - 1,000,000. EISRI 50,000 - 499,999.

Examples:

Oil spill at MAF tanker loading operation which arrives on local beaches requiring onshore and or offshore clean up operations.

Any physical damage caused to nature reserve area for rare species.

Localised contamination of a ground water resource making it unfit for human consumption or irrigation.




5. Massive Effect Extensive damage to attribute(s) of natural environment thereby affecting its ability to support human population or wildlife. Prolonged recovery period (several years) or site cannot be restored to satisfaction of interested parties. Clean-up and site restoration costs > US$ 1,000,000. EISRI > 500,000.

Examples:

Maximum credible release of PDO crude oil from MAF facilities such that oil is dispersed along several kilometres of beaches affecting recreational, fishing interests and water abstraction.

Widespread severe contamination of ground water resource making it unfit for human consumption or irrigation.

Any damage which affects the numbers of a rare species.

