Incident - Accident Reporting Procedure

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Accident-Incident Reporting Procedure

ACCIDENT-INCIDENT REPORTING

PROCEDURE

Document Revision Status

Nnochiri Ogbonna Michael Nnanna

0 15.06.13HSE

COORDINATORGM-ENGINEERING

SERV/ CORPORATE

MD

Rev.

Date Prepared Reviewed Approved

HAMMAKOPP CONSORTIUM LIMITED

HAMMAKOPP BASE

Km 25 Onitsha Owerri Express Way

Umuezedam Okija

Anambra State.

[email protected]

2013
mailto:[email protected]:[email protected]:[email protected]


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Accident - Incident Reporting

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TABLE of CONTENTS

INTRODUCTION 41.1 General 41.2 Objective of the Procedure 51.3 Purpose of the Procedure. 61.4 Definitions and Abbreviations. 71.5 References 72.0 Responsibilities 8

3.0 Incident Reporting, Investigation & Communication 9

Emergency Contacts 9

Emergency Flow Charts 10

4.0 Purpose of an Effective Investigation . 11

5.0 Major Incident Notification Process 12

Incident Potential Matrix 15

Immediate Incident Notification & Reporting Matrix 17-18

Attachments

Attachment 1 Accident Reporting Form-Blank Copy 19-26

Incident Notification Form

Near-miss Reporting Form

Detailed Incident Investigation Report Format


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REVISION HISTORY

Revision Date Page Description Approved

R0


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INTRODUCTION

General

Hammakopp Consortium Limited HSE Management System requires management

commitment at all levels as to ensure that all accidents are prevented and unsafe

conditions identified with control measures put in place to mitigate any undesired

occurrence.

Sound HSE MS implementation is geared towards accident prevention considering the

high cost (direct & indirect) of accidents to an organization.

Employees have the obligation to report unsafe acts and unsafe conditions, while

HSE advisors conduct risk assessments jointly with construction team as to identify

inherent hazards associated with all activities, and proffer controls as to prevent

accidents.

Reportable Acc ident Types;

Fire Incidents

Medical Incidents

Security Incidents

Environmental Incidents

Equipment/Facility/Asset Damage Incidents

Direct costs of an accident are;

Medical Costs:

Cost of treatment, additional associated medical costs, hospital and physician

bills, occupational therapy, prescription medicine and medical equipment

Compensation Costs:

Insurance, replacements, repairs and workmen compensation insurance policy

implementations.


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Indirect Costs of an accident;

Like an iceberg, the unseen indirect costs of accidents are much larger than the directcosts above. Indirect costs associated with workplace accidents and injuries include

damage to the equipment the worker was using, loss of work time, production loss and

cost to hire (a permanent or temporary replacement for the employee), training and re-

training, cost of accident investigation, legal or police charges etc.

Other indirect hidden costs include the possibility that the employer's insurance premium

may raise rise because of the accident. Indirect costs associated with workplace accidents

and injuries can total as much as three or four times the amount of the direct costs andmay amount to 30 times the amount spent for direct costs, depending upon the type of

accident that occurred.

Production delays/interruptions

Product and material loss or damage

Equipment or Facility Damage

Client Dissatisfaction

Employee Training Overtime Costs

Loss in productivity

Corporate Image/media

So every effort must be made to prevent accidents from happening!

1.2 Objective of the Procedure

The objective and purpose of this document is to provide Hammakopp Consortium

personnel with basic information that will serve as guidelines regarding standards of

accidents and incident reporting and investigation. It attempts to establish and define

responsibilities for different level of management as well as employee responsibilities in

the event of an accident. It also defines the various levels of accidents as it relates to

Hammakopp Consortium operations.

Some details represented in this document may be revised from time to time to meetchanges that may occur for various reasons. However, it is Hammakopps intention to

adhere to this procedure as much as practicable.


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1.3 Purpose of the Procedure.

This procedure will similarly fulfil the purpose listed below:

Documenting a procedure for accident reporting and investigation;

Establishing in clear terms reporting lines and timelines for reporting accidents

Provide the mechanism for rating accidents and their investigation levels

Identifying critical issues and potential constraints;

Defining responsibilities of the management and Employees

Facilitate the briefing of Hammakopp Consortium personnel and provide them

with a guideline regarding accident reporting and investigation.


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1.4 Definitions and Abbreviations.

Non-conformance- A condition or event which deviates from established procedures.

Near Miss- an incident that does not result in loss but could have, given slightly different

(but credible) circumstances

Accident- an unplanned, undesired incident which results in loss or damage to properties,assets, equipments, facilities, environment etc.

Loss- The unnecessary waste of resources, including:

PEOPLE: fatality, injury, illness

PLANT/EQUIPMENT: damage, repairs, replacement

PROCESS: interruption

AMENITY: environment pollution

GOODWILL: adverse publicity

1.5 References

Hammakopp Consortium Limited accident-incident reporting and investigation

Procedure.

Hammakopp Consortium Limited HSE Manual

Hammakopp Consortium Limited HSE Plan for construction activities

Accident report and investigation form.

.


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2. 0 RESPONSIBILITIES

Management-:

Ensure that all accidents/incidents and non-conformances are reported and

documented.

Ensure that immediate and remote causes of accidents are identified,

cascaded, and corrective actions taken to prevent the recurrence of an accident/

incident or non-conformance.

Ensure that unsafe conditions requiring management commitment are

addressed as to prevent unwanted occurrence.

Ensure the provision of resources required to address accident related issues.

Ensure timely provision of emergency / contingency equipments.

Maintain effective communication with responsible parties in the event of an

accident.

Ensure the mobilization of security personnel when required.

Employees

Ensuring their work activities does not harm themselves, others or the

environment.

Take reasonable actions to prevent incidents and non-conformances.

Report incidents and non-conformances immediately to their supervisor.

Identify unsafe conditions, proffer immediate remedial actions or report unsafe

conditions to their supervisor or HSE department.

Fill the HIR form when required.

Use fit-for-purpose equipments and tools to carry out work activities.

ERT/HSE

Initiates emergency response/ rescue operations

Communicates responsible parties and maintains effective communication


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3.0 INCIDENT REPORTING, INVESTIGATION AND COMMUNICATION

Incidents are reported immediately to supervisors, HSE advisors and management

depending on incident severity.

The incident reporting and investigation form is used for reporting, investigating and

tracking incidents to closure

Lessons from and information on non-conformances and incidents are communicated

using HSE Alerts, accident/incident review and HSE meetings and/or daily toolbox talks

mediums.

Emergency Contacts;

NAME DESIGNATION PHONE

K. C AKUMA MD 08033241099

NNANNA MICHAELGM Engr & CorporateServices

08036719422

CHUKWUNWIKE ALEX GM Projects 08033402965

CHUKWUDUM IKENNA Legal/SCD/Pro/Contracts 08034727156

FEROZ JADOON Construction/Project Manager 08037936436

JOITI KUMAR AGM - Maitenance 08030896640

HUSSEIN MOHAMMED Senior Site Engineer 08160595035

WILLIAMS OLATOYE Engineering Coordinator 08033150389

NNOCHIRI OGBONNA HSE Coordinator 08036719585

ESIEKPE ISAAC HSE Supervisor 07034547809

HENRY IWUCHUKWU Chief Security Officer 08038804602EWUZIE UCHE Transport/Logistics Officer 08060824186

COKER MICHAEL Asset Officer 08034934641

OGBONNA FRANCIS Site Nurse 08075790861

MIRIAM IFEANYI Base Nurse 07065322241

JUDITH OKOLI HR Officer 08075790867

ALEX ISOGIE HSE Officer-PH Base 08158990940

SOLOMON HSE Coord- Uyo Base 08037534461


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Emergency Flow Chart

Call On-Scene

Commandant

(OSC)

GM.

08036719422

,07028180801

or Code 1045

HSE Co-ord, Site/Base

Nurse will assess

situation and take

action.

08036719585/

07065322241

Coordinate with Project

Mgt. Team.GM-Projects-08033402965

PM/CM-08037936436

Access theSituation & report

Provide adequate

First Aid or Med.

Assistance.

Investigate , Report &

make

Recommendations

Project Mgt. team to

determine course of

action

Moves Victim to

Hammakopp

Retainer Clinic

Medevac +

Evacuation Required?

Hamakopp to initiate

Evacuation . Stabilize

Contact Client Site

Rep.

Investigate

&Report to Client

24hrs

Contact Project

Mgr to MEDVAC +

Evacuate Victim

Coordinate with

Evacuation/

MEDEVAC Provider

Inform the Base

Office

Inform MEDEVAC

Provider

MEDICAL /EVACUATION EMERGENCY REPONSE FLOW CHART

Case Cannot be managed

InternallyAdminister First Aid and

Communicate

MEDEVAC ProviderIf needed

No need for MEDEVAC

Case Can be

managed

internally

08033241099---- -MD

08036719422------GM-Engr Services/Corporate

08033402965------GM-PROJECTS

08034727156------Legal/SCD/Pro/Contracts

08037936436------PM/Construction Manager

0816059503-------Hammakopp const. Abuloma

07065322241------BASE NURSE

08035973880 -----SITE NURSE

08036719585------HSE COORDINATOR

07034547809------HSE SUPERVISOR.

08063572178 -----Medical-Medridian Hosp-PH

08034877736-----HSE OFFICER-Abul oma, Site PH08063487200----HSE OFFICER- Ichi Site, Anambra

08033241099---- -MD

08036719422------GM-Engr Services/Corporate

08033402965------GM-PROJECTS

08034727156------Legal/SCD/Pro/Contracts

08037936436------PM/Construction Manager

0816059503-------Hammakopp const. Abuloma

07065322241------BASE NURSE

08035973880 -----SITE NURSE

08036719585------HSE COORDINATOR

07034547809------HSE SUPERVISOR.

08063572178 -----Medical-Medridian Hosp-PH

08034877736-----HSE OFFICER-Abul oma, Site PH08063487200----HSE OFFICER- Ichi Site, Anambra

Phone Lines

MD-07028002304,08033241099

DPR-084-3290000 &084-4611777

FEMENV-08032557931.

Retainer Clinic- Our Lady of

Lourdes Ihiala 08135700630

Retainer Clinic- PH-Meridian:

08063572178

MD-07028002304,08033241099

DPR-084-3290000 &084-4611777

FEMENV-08032557931.

Retainer Clinic- Our Lady of

Lourdes Ihiala 08135700630

Retainer Clinic- PH-Meridian:

08063572178

Important Lines

CaseCannot be

managed

Internally

Emergency

Incident Observedat Site/Base/

Camp


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4.0 PURPOSE OF AN EFFECTIVE INVESTIGATION.

A good and timely incident investigation can help us:

describe what happened

determine the immediate and root causes

evaluate the risks

develop controls

define trends

demonstrate concern

And which ultimately lead to:

fewer incidents

reduced incident costs

lower incident rates/potential

increased confidence /morale (client & employee)

higher profit margins

4.1 Which Incidents Shou ld Be Investigated?

We must investigate all incidents to determine which has the potential for major or

serious loss!

We should give special attention to those with high potential for loss

5.0 INCIDENT CLASSIFICATIONS

There are three major classes of incidents.

1) Major accidents

2) Serious accident


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3) Minor accidents.

MAJOR INCIDENT NOTIFICATION PROCESS.

Overview

Hammakopp Consortium employees are responsible for preventing incidents by

following safe and environmentally sound practices and procedures. When a Major

Incident occurs, local employees first priority is to respond to the immediate needs of

the situation and notify direct supervisors and managers to provide assistance with this

response. Additionally, for Major Incidents, an immediate call to the operating base is

required. The single hotline call ensures that support departments such as Legal,

Contracts, Assets and Logistics, the HSE Departments, security and appropriate

Management executives are kept informed of Major Incidents. This notification process

reduces the burden on local management and personnel and allows them to be

dedicated to emergency response and external notifications (e.g., responders,

agencies, clients, etc).

5.1 MAJOR INCIDENT DEFINITION

Incident involving loss of life or major injuries (e.g., amputations, serious eye and head

injuries, injuries requiring emergency hospitalization, etc).

Extensive property or equipment damage in excess of $50,000

Fatal road traffic accidents resulting to death(s).

Explosions, loss of radiation sources, or blows out events where Hammakopp

Consortium personnel or equipment are present.

Fires requiring outside assistance from emergency services.

Radiation releases exceeding the reportable quantity

Chemical spills or releases that meet or exceed the l reportable quantity; any

spills of 55 gallons (208 liters) or more which occur at a clients facility, during

transport, or at a public location

Any incident involving Hammakopp Consortium employees, products or

services at a client or Hammakopp Consortium location with likely public

consequence or potential media attention


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Security Incident: may include, but not be limited to threats to personnel or

property (e.g., bomb threats), requiring the need to evacuate personnel from a

location, reports of actual or threatened extortion, kidnapping of personnel orcontractors, reports of civil, political, or labor unrest in a location.

Loss or theft of explosives or radiation sources.

Collapse of buildings

Natural disaster e.g flood, earthquake

5.2 SERIOUS ACCIDENTS DEFINITIONS

Any incident not mentioned in the previous definitions involving the following

Personal injury involving medical beyond first aid.

All days away from work cases

Fires handled by local staff

Property or equipment damage not exceeding $10,000 dollars

Chemical spills or releases that meet or exceed the local reportable quantity; any

spills of 55 gallons (208 liters) or more occurring at Hammakopp Consortium base

only.

5.3 MINOR ACCIDENTS DEFINITIONS

Any incident not mentioned in the previous definitions involving the following

Personal injury requiring first aid treatment.

Minor property damage (dents, broken minor glasses) between $1-$10,000 dollars.

Chemical spills or releases not exceeding the local reportable quantity; occurring at

Hammakopp Consortium bases only.


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5.4 HOTLINE CALL PROCESS

An employee involved in, or witnessing, an incident will report the incident to their

supervisor. If the supervisor is not available the employee is to contact the local or

local HSE Rep or the Site Manager (Reference emergency contact numbers).

The supervisor, either alone or in conjunction with the local HSE representative and/or

local emergency response coordinator, decides if the situation is a Major Incident. If

yes, it must be reported to the responsible manager and the HSE Coordinator. This

report must be madeimmediately after incident stabilization and at least within two

hours.

For severe incidents that do not appear to meet the exact definition or examples of a

Major Incident, please use your best judgment and initiate a hotline call as appropriate.

(When in doubt, always report)

In situations where the major incident scenario is evolving (e.g., loss of source,

employee hospitalization), the employee making the notification and/or the Emergency

Coordinator is expected to make a follow-up notification to provide updated or closure

information when appropriate. This information will be updated in the written record

and communicated to the appropriate authorities. Phone calls must give the following-:

Name of Caller:

Callers contact number:

If caller is an employee, supervisor or other

Type of Incident:

Affected Employee Name:

Specific location ( site, customer site or other):

Address:

Description of the incident: A clear description of the incident must be provided

by the caller.

Any immediate response need: Information on additional assistance that may

be needed.

Other parties notified (Client, personnel, government agency, authorities, etc.)


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5.5 INCIDENT POTENTIAL MATRIX

Incident Severity.

Number of persons Involved.

0 1 2-10 11+

Major 1 Level 2 Level 1 Level 1 Level 1

Serious 2 Level 3 Level 2 Level 1 Level 1

Minor. 3 Level 3 Level 3 Level 2 Level 1

This matrix determines the investigation level of accidents in Hammakopp. However in

arriving at this format, the major Considerations are as follows-:

the severity of the incident (or its potential); and

The number of persons involved (or its potential.)

Selection of investigation team members depend upon the determination of the severity

of the incident.

5.6 WHO SHOULD INVESTIGATE INCIDENTS?

From the matrix above, these are the responsibilities as it applies to the different levels

in accident investigation in Hammakopp Consortium Limited-:

Level 1 Investigations are undertaken by the following-:

Line Supervisor/Manager.

Location or Project Manager/Project Engineer

MD/or management Rep.

HSE Coordinator/Manager.

Local HSE Representative

Others as deemed necessary (e.g., CSO, PRO/CLO, Asset/Logistics, staff

personnel)


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Level 2 Investigation is undertaken by the following-:

Line Supervisor/Manager - Leader

Group or Department Manager

Local HSE Representative

Others as deemed necessary (e.g., staff personnel)

Level 3 Investigations are undertaken by the following-:

Line Supervisor/Manager - Leader

Others as deemed necessary (e.g., staff personnel)

Supervisors should take the primary investigative role because they know:

An accident occurred in their area

The decision(s) made, equipment used, and

other factors which may have caused the accident

The capabilities and limitations of the

personnel involved in the accident

The procedures that were used or should

have been used


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5.7 HAMMAKOPP IMMEDIATE INCIDENT NOTIFICATION AND REPORTING MATRIX.

INCIDENT SEVERITY

PERSON TO CALL:MAJOR(within 2hours)

SERIOUS orSignificant NearMiss(within 12hours)

MINOR or NearMiss(within 24hours)

BASE/ENGINEERING CONTACT.

Name ..............Michael Nnanna

Mobile phone:..08036719422, 08075790844

Phone / e-mail

Phone / verbal Phone / verbal/ e-mail

PROJECTS CONTACT.

Name ................Alex Chukwunwike

Mobile phone:....08033402965, 08075790845

Phone / e-

mail

Phone / verbal Phone / verbal

/ e-mail

MAINTENANCE CONTACT.

Name ...................Joythi Kumar

Mobile phone:................, 08075790872

Phone / e-mail


LEGAL/SCD/PRO CONTACT.

Name ...................Ikenna Chukwudum

Mobilephone:................08034727156,08075790846

Phone / e-mail


CONSTRUCTION CONTACT

Name . .........................N.F.Jadoon

Mobile phone.....................08075790847

Phone / e-mail


CONSTRUCTION PH BASE CONTACT

Name . ..............Mohammed Hussain

Mobile phone.........................08158990938

Phone / e-mail


HSE CONTACT.

Name .................Nnochiri OgbonnaMobile phone......08036719585, 08075790850

Phone / e-mail Phone / verbal Phone / verbal/ e-mail

ASSET CONTACT.

Name ...............Micheal Bayo Coker

Mobile phone......08034934641, 08075790862

Phone / e-mail


TRANSPORT CONTACT.

Name ................Felix Ewuzie Uche

Mobile phone......,............ 08075790852

Phone / e-mail



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HAMMAKOPP HSE PH BASE CONTACT.

Name ..............................Alex Isogie

Mobile phone.........................., 08158990940

Phone / e-mail


HAMMAKOPP HSE UYO BASE CONTACT.

Name ..............................Solomon

Mobile phone.........................., 08037534461

Phone / e-mail


CSO CONTACT.

Name ..................Iwuchukwu Hilary

Mobile phone.........................., 08075790868

Phone / e-mail


EMERGENCY RESPONSE TEAM

Name . Isaac Esiekpe-08075790851.

Name ..............Emmanuel Nworie-08063487200

Phone / e-mail


CLINIC CONTACT

Name: Ogbonna Francis -08075790861

Name: Miriam Ifeanyi - 07065322241

Phone / e-mail



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ATTACHMENTS-:

ATTACHMENT I ACCIDENT REPORTING FORM-BLANK

ATTACHMENT 2 NEAR-MISS INCIDENT REPORT FORM\

ATTACHMENT 3- DETAILED ACCIDENT-INCIDENT REPORT FORMAT


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INCIDENT REPORT FORM

DATE OF INCIDENT: TIME OF INCIDENT:

LOCATION OF INCIDENT:

INCIDENT/ACCIDENT TYPE (TICK APPROPRIATE BOX)

INDUSTRIAL SECURITY

LOST TIME INJURY COMMUNITY

MEDICAL TREATMENT CASE ENVIRONMENTAL/SPILL

FIRE NEARMISS

MARINE OCCUPATIONAL HEALTH

ROAD TRAFFIC OTHERS

NATURE OF SECURITY INCIDENT: ________________________________________

NATURE OF COMMUNITY INCIDENT: ________________________________________

STAFF/EQUIPMENT INVOLVED: ________________________________________

EVENT LEADING TO THE INCIDENT:

IMMEDIATE ACTION TAKEN:

____________________________________________________________________________________

____________________________________________________________________________________

_________________________________________________________________________________

INCIDENT/ACCIDENT ANALYSIS/CONCLUSION:

________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________

RECOMMENDATION:

NAME OF REPORTER SIGN. DEPT. DATE

FURTHER INVESTIGATION REQUIRED? [YES/NO] HEAD OF DEPT. SIGN/DATE.

NOTE: THIS FORM MUST BE COMPLETED AND FORWARDED TO HSE COORDINATOR WITHIN 24HRS OF INCIDENT.


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NEAR-MISS REPORT FORM

PROJECT: ______________________________ LOCATION : ____________________

PLACE OF INCIDENT: ______________ DATE:_____________ TIME:______________

PERSONNEL INVOLVED EQUIPMENT/MATERIALINVOLVED

1. ----------------------------------------- 1. ------------------------------------------

2. ----------------------------------------- 2. ------------------------------------------

3. ----------------------------------------- 3. ------------------------------------------

DESCRIPTION OF NEAR-MISS INCIDENT:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

________________________________________________________________________________________________________________________________________________________________________

IDENTIFIED REASONS FOR THE INCIDENT:

____________________________________________________________________________________

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

REVIEW/RECOMMENDATION/LESSON LEARNT TO AVOID RE-OCCURRENCE:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

____________________________________________________________________________________

REPORTED/OBSERVED BY: _________________ SECTION/DEPT._____________________

RECORDED BY: _____________ DESIGN:_______________ SIGN:____________


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DETAILED INCIDENT INVESTIGATION REPORT FORM

1 Anomaly/Incident Description Summary (Facts only) Enter here a brief description of the incident.

2 - Incident Classification Verification

Date: Time: Activity:

Site: Exact Location: Report Number:

Type DamageCategory

Severity Human LossClassification

Anomaly

Near Miss

Incident

Human Loss

Environmentalloss

Prod/MatLoss

Media

Actual Potential First Aid

Medical Treatment Case

Restricted Work Day Case

Lost Time Injury SingleMultiple

with estimated_Days Lost

Illness Fatality

1 - Minor2 -

Moderate

3 - Serious

4 - Major

5 -Catastrophic

1 - Minor2 - Moderate

3 - Serious

4 - Major

5 - Catastrophic

3 - Incident Information

3.1 - Human Loss/Injury & Victim Information (remove section if not used)

Name (s) Age Senioritydate

COMPANYContractor

orThird Party

Jobfuncti

on

Hrssince

lastsleep

Hrsslept

lasttime

Hrson

duty

Typeof

loss

Indicate details on injuries for each of the persons above

Injury Body partsaffected

Dayslost

(estimated)

Medical Officer Name: _____________ Signature ______________

3.2 Vehicle Incident Information (Remove section if not used)

Was vehicle travelling in convoy : Yes No Was the driver the only occupant? Yes No

Was Vehicle Company Owned Rented/Leased Personal Vehicle On Company Business Yes No

WeatherConditions

Road Type Accident Type

Dry Paved Unpaved Hit vehicle in front Sideswipe

Wet/slick Off road Curve Hit from behind Passing

Clear Up a grade Downgraded Backed into Being passed

AHeadBFace

HFingersILegs

A CutB Heat BurnCFracture/breakD Amputation

H ChemicalburnISprain/strainJ BruiseK Crushing


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Dust Narrow Poor surface Hit stationaryobject

Hit & Run

Fog Hit pedestrian Hit animal

Rollover Ran off road

Alcohol or drugs involved? (Testingrequired)

Yes No Results of alcohol test _____ g/l Measured __ hrs after event

Speed when accidentoccurred

______ km/h Driving Certificate held? Yes No

Driving monitor present and working? Yes No Charged by Police? Yes No

All persons wearing seatbelts? Yes No Defensive Driving Training up todate?

Yes No

3.3 - Environmental Incident Information (Remove section if not used)

Result Details

Vegetation damage Release to water way Amount spilled or

discharged:

Unit

Soil contamination Released to air Material name or code :

Ground watercontamination

Marine life damage Duration of discharge: hrs Min


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3.4 - Asset, Material or Production Loss Information (Remove section if not used)

Other Loss Information

(Equipment, property, products, information, time or other including those of Third Party)

Type:

Description of loss Quantity

Unit

4 - Incident Cost Estimate (Remove section if not used)

Injury/Illness Costs($000) Automotive Costs ($000)

Environmental Costs($000)

Other Costs ($000)

Lost WorkDays

Replacements

LostProducts

Replacements

Temp Staff Repairs Remediation Repairs

MedicalCosts

3rd PartyRepairs

LitigationLostProducts

Litigation/Other

Litigation/Other

OtherLostRevenue

Total Total Total Total

Remarks :

5 - Investigation

Name of Manager leading the

Names of other team members:

Investigation Section 5.1 - Immediate Causes (Key Words)Contact/ Fall Electrocution Marine Trans ort incidentExposur

Struck by Drowning Gas leak

N/A Caught between Vehicle incident Liquid hydrocarbon leakExplosion or burns Air transport incident Other

Investigation Section 5.2 - Immediate Causes (Practices & Conditions)

Unsafe Procedure Material tools & e ui ment Unsafe Position / PostureFailing to secure plant Using Unsafe Loading / Lifting

Failure to follow procedure Unsafe Use of Correct Tools / HorseplayFailure to warn of inform Servicing equip in Failure to Make Plant SafeOperating at improper speed Failure to check equip Unsafe Mixing, Placing,erformin hazardous liftin or loadin Dru induced Servicin e ui in o eration

Unsafe Inade uate Guards or Barriers Pressure ex osure Substandard Housekee inSituation Inadequate PPE Slippery surface Corrosion / Slow Damage

Defective Tools, Equip, or Mat. Defective Plant / Excessive Noise orCongestion / Poor Access Wear and tear Inadequate VentilationInadequate Warning System Radiation exposure Safety devices inoperable

Inadequate Illumination Hazardous Atmospheric

Investigation Section 5.3 - Root Causes

(Which of the following Human and/or Job Factors were the Basic Causes of this accident?)

Human FactorsJob Factors

Lack ofknowledge

InadequateTraining

Inadequate Leadership / Supervision Inadequate Job Planning

Inadequatecapability

ImproperMotivation

Inadequate EngineeringInadequate tools, materials,

equip.


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Stress Fatigue Inadequate Purchasing Inadequate Work Standards

SubstanceAbuse

InattentionInadequate Work Instructions

ProceduresInadequate Maintenance

Lack of

AwarenessLack of Sleep Inadequate Risk Assessment

Inadequate

Plant/Machinery/Equip.Inadequate Definition of

ResponsibilitiesAbuse or misuse

Investigation Section 5.4 - Root Cause

(Refers to MS Dysfunction)

The fundamental or root causes are selected from one of the 14 elements listed belowRespect of laws &

regulationsRespect for the

EnvironmentEmergency

PreparednessCriminal act / ill will

ManagementResponsibilities

Safeguarding of Health Incident Analysis Other

Operational Responsibilities Contractors & Suppliers Audits & Inspections

Risk Evaluation &Management

Competence & TrainingPerformance

Improvement

6 - Other Information (Interviews, Pictures, etc.)

Include in this section a summary of all the information collected during the investigation. Placesupporting documents at the end of the report as Appendix.

1) Winess Report2) Preliminary Incident Notification

3) Investigation Report4) Photograph

7 Cause Tree Analysis State Causes (FACTS-ONLY)

Insert the cause tree analysis in this section.

8 - Corrective Actions

Enter below corrective actions required to address immediate, basic and root causes. Specify WHO and WHEN.

ItemNo Recommendation

Action Item Person

Responsible

TargetDate

Complet

ion.Date

Remarks

1

2

3


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Procedure.

Doc. No.:

Rev. No.:0

Page 26 of 26

9 - Review and Endorsement

Comments by Reviewing Manager

Endorsements

Reported By (Name): Signature: Date:

Noted By (Name): Signature: Date:

For HSE Division: Signature: Date:

Documents

Incident - Accident Reporting Procedure