14 incident reporting

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Chapter 14INCIDENT REPORTING

CONTENTS1. Scope2. Purpose3. Definitions4. Responsibilities5. Instructions6. References7. Attachments

1.0 SCOPETo be applied for every incident that may occur on construction/opertation Projects. No incidet or accident should be hidden from management.

2.0 PURPOSEPurpose of this procedure is to ensure that all incidents are reported in a logical and consistent manner, to give guidance on preparation of Accident Reports and to capture all information necessary to identify acceident cause factors. Prevention of accidents adds to health & proficient working on sites. It adds to value engineering on production. It results in saving life of human. It rsults in professionalism. It results in capacity building potential.

3.0 DEFINITIONSDefinitions regarding certain terms

1. Safety means safety, health & environment disciplines to support project activities2. Company means an organization carrying out or prosecuting project3. Contractor means organization that has won project from client4. Subcontractor means an organization that has won part of a project work from Contractor

organization5. Client means an organization entitle Company in contractual terms that has entrusted project to

organization of Contractor6. Personnel means all personnel involved on project site activities7. Responsibility means job & contract responsibility8. Training means training imparted for specific safety topic on job on project site9. Management means organization top, middle & lower management10. Safety Manager means a person with job title Safety Manager deployed by certain organization11. Project Manager means a person as such with PM title deployed by Contractor12. Engineer means a person appointed by client or client company for an overall project responsibility

Accident - Any event that results in property damage or personal injury or bothIncident or Near Miss - Any event that has a potential for a higher severity in terms of

property damage or personal injury or bothCategory A - Form used for recording all injuries and property damage incidentsCategory B - Form used for investigating serious or potentially serious incidents

and recording a root cause analysis

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CONTRACTOR EPC CONTRACTOREMPLOYER Project Owner

RESPONSIBILITIES IN GENERAL RESPECTING CERTAIN CONTRACT POSITIONS

1. Project Manager responsible for overall obligations, to provide schedule, all resources, direction, engineering resolutions.

2. Site Manager responsible for overall site prosecution management over works & subcontrcators.3. Site Safety Officer responsible for overall safety management on site & report to Project Manager /

Site Manager / Corporate Safety Manager4. Construction Manager responsible to arrange all safety related resources & provide site team all

requirements 5. Project Site Engineer responsible to carry out safety issues within section6. Site Safety Inspector/Engineer responsible to supervise safety measures on site & control safety

issues, should bring to site line management to adopt correct measures.7. Site Foremen responsible for compliance of safety measures as standards or as directed8. An individual working on site responsible to maintain safety measures. In case, missing, should

bring to site team attention

4.0 RESPONSIBILITIES4.1 Site Manager

Ensure that incidents are being investigated & reported.Ensure that victims are immediately allowed first aid following which, hospitalisation is provided.

Ensure that remedial actions are being dealt with in an effective & timely manner.Immediately, report all accidents or serious incidents to Employer’s contract engineer, Construction Manager and contractor’s

Project Manager, who shall immediately inform employer’s Project Manager.Comply with all accidents related procedures of reporting & investigating as well as, extending medical aid & hospitalisation.

4.2 Contractor Health, Safety, Environment and Security Manager Immediately report all accidents or serious incidents to Site Manager for

necessary management actions. Immediately act for meeting emergencies procedures including reporting &

medical provisions. Responsible for development of this procedure and monitoring compliance. Initiate investigation process

4.3 Subcontractor’s Site Manager Shall ensure that this procedure is being implemented correctly.

4.4 Contractor And Subcontractor Site Supervision Shall report all accidents or serious incidents immediately to their respective

HSE Manager. Shall participate in administration of this procedure. Shall ensure that recommendations resulting from whatever investigations are

being acted upon.4.5 Subcontractor HSE Manager

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Shall facilitate implementation of this procedure, whenever required by identifying & interacting with witnesses and collecting all evidences required in connection with investigation interrogation process.

Shall participate/cooperate in investigation process. Shall liaise with site medical department in reviewing ‘Category A’ reports and

identifying its trends or concerns. Immediately report all accidents or serious incidents to Subcontractor Site

Manager and Contractor HSE Manager.4.6 SUBCONTRACTORS

All Subcontractors shall be required to comply with this procedure.

5.0 INSTRUCTIONS5.1 This procedure has been broken down into two stages, Category ‘A’ form is for

minor incidents to enable Site Safety Representative to maintain a log of all incidents and accidents establishing trends, cost analysis and construct a project file.Category ‘B’ proformas are structured to enable effective investigation of all serious accidents or incidents and to arrive at root cause analysis.

5.2 Guidance on the use of incident report forms.5.2.1 Category ‘A’ Reports - (Attachment 7.1)

To be documented in medical centre and with Safety Representative and recorded using, following guidelines:-- Incident reports shall be marked/given a sequential number.- Type of incident, to be ticked as appropriate.- Description of incident medical/safety representative provides brief

details.- Potential severity - for certain near miss incidents or situations that

could have resulted in more serious injury/property damage.- Property damage report is Self explanatory- Injury report to be filled in by medico and injured party wherever

relevant for possible application.Category ‘A’ report proforma can be used as a “standalone” document. Medico retains a copy of all completed forms to log all injuries and Site Safety Representative would track all property damage incidents by maintaining a record on site.

5.2.2 Category ‘B’ Site Investigation Result Sheet - (Attachment 7.2 )Investigation results sheet should be completed by Site Safety Representative using following guidelines.Note: Site Safety Representative has a co-ordinating role regarding

preparation of these reports and shall establish an investigation team (in conjunction with Site Manager) to establish accident cause factors.

a) Immediate Causes - Unsafe acts and conditions to be identified using following guidelines.

S #

Unsafe Acts Indications Remarks

1 Operating equipment without authority

Equipment not checked for

Generally not care for

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performance, 2 Failure to warn or educate No toolbox talk

delivered, No warning given

Generally formalized only, not realized

3 Failure to secure Ignorance by worker or carelessness or overconfidence of correct use

Very common among workers, even safety belts/body harnesses are avoided

4 Operating outside of designlimitations

No authority instructed about rated speed of tool, Worker unable to read description on tool

No body cares, even safety personnel ignore

5 Removing a safety device For personal convenience or ease of working, removed devices like guides or insulations

Workers avoid device for ease of working

6 Using defective equipment Routine maintenance failure, no competent person checked operational effectiveness of tool

Nobody cares for an earliest repair or replacement

7 Not wearing personal protection equipment

General neglect by workers to avoid PPE just for little extra comfort, not using safety goggles, hardhats or safety shoes for various excuses of difficulty in operation or wearing

Hardhats in hot areas are avoided, safety shoes are avoided, overalls are avoided. One foreman expressed an excuse for havinghead ache when hardhat is worn!!!

8 Improper lifting technique Lift on self practised style without caring for instructions given by manufacturer or method as delivered during toolbox talk

For fast running on job production, safety techniques are

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ignored9 Improper placement of

individual/materialNeglect of material sorting & proper handling, lack of site supervision & safety surveillance

Nobody cares in general

10 Improper position for task Not caring about tools handling but talking/ using mobile phone during tools operations

Nobody cares in general. Policing cannot be done on site.

11 Servicing equipment in operation

During operation, not caring about results or consequences, but trying to check defects


12 Horseplay or other non-work related activity

Playing with equipment or tools for own pleasure without caring for adverse consequences


13 Under influence of alcohol, drugs, medication

Drinking without permission on works that hangs on a person


14 Other identified acts Using hoisting equipment for personnel transport without permission, standing below equipment, while it operates, neglect of operations, leaving tools in operating condition unattended, avoiding safety belts or harness


Memories about safety issues:1. As a project manager, personally I have been inclined to supervise many senior

personnel & thousands of workers. 2. What I experieced is not convincing. Asked many engineers & foremen about

notusing hardhats when such equipment had been provided by organisation? 3. Surprising response received. 4. Many responded that hardhats were kept in offices or in stores.

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5. I asked many to go back to store or offices & bring back hardhats or keep respective heads in offices or stores.

6. One foreman replied that he ws not willing to use for it caused invonvenience to his head due to having head stress.

7. I instructed many personnel go back home shouly they not being interested to work dressed with PPEs.

8. I have seen many accidents due to not wearing PPEs by workers. 9. I have seem many finger cuts resulting inbleeding due to ill use of grinders or drills. 10. I chaired many meetings with all supervising staff stressing for toolbox talks in

details, but effect was nit witnessed to requirements. I could not find any valid reason for not using PPE at costof life.

11. One person on a hospital project in Jeddah working on groun for a underground tank where RCC preparation activitivies were ongoing.

12. I had asked all workers while visitng sites, to use hardhats at least but, instruction was ignored or hardhats were carried byhands. Person did not use hard had.

13. Unfortunately, leg slipped from ground & person fell into deep trench. Person’s head struck with forwork batten & life was lost.

14. I heard about this news when I was out of that organisation.15. I have even observed certain stupid personnel not using safety boots for reason of

being tightely laced. In turn, sleepers are used or chappals are used. 16. Some workers were seen workingon higher levels without using even safety belts,

though body harness should be used. Excuse explained was that it was not convenient for them to work fast. Evetytime, belt was required to be removed & anchore agains. Life line requires to be provided but, that too is not utoilised propely.

17. Until, construction team does not respect life values, safety managemenet cannot be enforced. Policing cannot be suggested all times.

S #

Unsafe Conditions Indications Remarks

1 Inadequate guards or barriers.

Protection to work areas are not made adequate that causes undue situations to result in accidents.

Often noticed on sites but no action is promptly resorted to

2 Inadequate/improper protected equipment

Due protection is not provided on equipment or tools.


3 Defective tools, equipment or materials

Tools are not regularly inspected by experts from operational safety viewpoint.


4 Congested or restricted areas of work

Work area not being tidy during work time leading to crashes. Tiding

Often noticed on sites but no action is promptly

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activity conducted only during/before client’s inspection

resorted to

5 Inadequate warning systems Required warning signs not installed for danger informations.


6 Chemical hazards Area remain unnoticed even by smaller quantity of hazardous materials being available.

Sometimes neglected

7 Housekeeping Poor house keeping & no one to ensure good general arrangement for a comfortable working.

Often noticed on sites. Actions are sometimes resorted to

8 Noise exposure Equipment & tools resulting in excessice noice leading to hearing impairment temporarily.

Often noticed on sites. Hearing aids are used sometimes.

9 Radiation exposure Very serious issue as can effect body permanently. Due protection is required.

Should be protected in plans.

10 Temperature extremes Very common in hot weather areas particularly in arabian gulf working areas where 4 to 50 degrees celcius is often.

Often noticed on sites. Actions are resorted to

11 Poor/excessive illumination Internal areas of building are not adequately illumined due to lack of electrical arrrangemennts leading to unpredicted accidents.

Often noticed on sites. Actions are taken to go ahead with work but, electrical cables are not propely routed

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12 Ventilation inadequate Area internal of buildings, basements, water or other tanks etc. are prone to ventilation issues, which is not an easily provided element.

Often noticed on sites. Artficial compressed air should be provided where necessary but ignore in many cases.

13 Other identified features Base scaffolding, lack of handrails on roof, lack of safety equipment, misuse of PPEs, shortage of cold & hot drinks for workers, lot of over time working, lot of night working. No entertainment.


Note: Unsafe Act should describe non acts/bad acts or omissions, which lead directly to incident.

Unsafe conditions should describe situation, systems, equipment or some other solutions that should have been provided with to prevent incidents/accidents.

b) Basic Causes - Preconditions that lead to unsafe act or conditions may include as indicated within following tabule:

S # Preconditions that lead to unsafe act or condition

Remarks

1 Failure to react to an unusual situation (training of new procedure, personnel, equipment, process and/or material).

Not imparted with due to neglect by officials

2 No instruction provided or available. No toolbox talks conducted

3 Failure to correct existing situation. Carelessness/ignorance/no problem attitude

4 Instruction/training inadequate or not understood.

Not confirmed by concerned officials

5 Supervision failed to explain reasons or justify. Neglect of responsibility

6 Supervision failed to listen. Neglect of responsibility

7 Duties and task not clear. Neglect of responsibility

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8 Pressure of immediate tasks. Lack of schedule & confidence

9 Responsibility not clear or not understood. Lack of awareness of job

10 Too many decision makers giving instruction. Incoherent team11 Authority inadequate to manage situation. Lack of leadership12 Decision to exceed authority Lack of leadership13 Decision avoidance. Lack of leadership14 Instruction failed to produce desired results. Lack of

responsibility15 Subordinates failed to use initiative. Lack of leadership16 Moral, tension and stress causing situations. Lack of leadership17 Job descriptions not adequate Lack of leadership18 Honest error, wrong action taken. Lack of leadership19 Lack of co-ordination/team work. Lack of leadership20 Poor co-operation. Lack of

leadership/coordination/communication

21 Faulty inspection and maintenance. Lack of leadership & supervision

22 Poor work control/co-ordination leading to poor site conditions.

Lack of leadership & supervision

23 Work load too much/too little Lack of leadership over controls

24 Staff shortages high turnover/absenteeism Lack of leadership over controls

25 Personality type e.g. impulsive, excitable, lazy etc.

Lack of leadership over controls

26 Poor work habits, taking short cuts, careless with tools.

Lack of leadership & supervision

27 Work assignment - unsuited for particular individual

Lack of leadership & supervision management

28 Inadequate delegation or development of subordinates.

Lack of leadership & vision

29 Health and impairment of individual. Lack of leadership & vision

30 Domestic or other external influence Lack of leadership

c) Root Causes- General failure types found in accident causes can be listed as follows:-Procedures - inadequate quality of existing procedures regarding application, availability, realism and understanding caused by:

S # Inadequate quality of existing procedures regarding application,

availability, realism and understanding caused by:

Remarks

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1 Inadequate team that developed procedure Incompetent team management

2 Inadequate feedback about procedure Lack of leadership/communication

3 Personnel not informed about procedures Lack of leadership/communication

4 Inadequate indexing or filing system. Lack of leadership management

5 Lack of requirement to have works procedures Lack of leadership management

S # Conflicting targets Remarks

1 Conflict between production and safe working practices

Lack of leadership

2 Conflict between financial priorities and safe working practices

Lack of leadership

3 Conflict between social and domestic priorities on safe working practices

Lack of leadership

4 Conflict between individual priorities and safe working practices.

Lack of leadership

S # Communications - difficulties caused by: Remarks

1 Language problems cultural barriers Lack of leadership2 Lack of clear lines of communication Lack of leadership3 Inadequate feedback (e.g. toolbox talks) Lack of leadership4 No standardisation of information formats Lack of leadership5 Lines of communication overloaded Lack of leadership

S # Hardware - quality, availability of tools and equipment caused by:

Remarks

1 Inadequate specification of equipment Lack of leadership controls

2 Wrong components purchased/used Lack of leadership controls

3 Equipment may not be available leading to improvisation

Lack of leadership control & vision

4 Defective equipment Lack of leadership controls

5 Age of equipment compared to life expectancy. Lack of leadership & vision

S # Design - Inadequate design criteria of plant and equipment caused by:

Remarks

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1 Design not fully understood to operate safely Lack of leadership coordination

2 Poor specifications leading to substandard materials and inherent weakness in system.

Lack of leadership coordination & vision

3 Specification not complied with. Lack of leadership supervision

S # Environmental conditions - A situation which may influence the individual or

workplace caused by:

Remarks

1 Poor morale, this can be caused by a number of situations e.g. unfair enforcement of rules, weak discipline, rule changes etc.

Lack of leadership/Bad team management

2 Physical deterioration, caused by working long hours, subject to undue pressure etc.


3 Emergency or unusual situation with staff unable to cope with or respond.


4 Information not correct or supplied. Lack of leadership/Bad team management

5 Poor co-ordination between departments causing interface problems.


6 Circumstantial factors, such as domestic pressures, homesickness, non payment of salaries in time, reducing salaries, not promoting when due etc.


S # Training - Shortcomings in skill and knowledge caused by:

Remarks

1 Ineffective pre-employment selection. Bad HR management

2 Prior education not compatible with job requirements

Bad HR management

3 No structured planning of training programmes Bad HR management

4 No assessment of training effectiveness Bad HR management

5 Ineffective training Lack of leadership management

6 Training not appropriate for personnel it aimed Lack of leadership

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at.7 Housekeeping and other site conditions that

may influence acts and omissions.Bad team management

S # Organisation - Shortcomings in structure of organisation leading to

inadequate operation of a company or project caused by:

Remarks

1 Inadequately defined departments or parts of organization.

Bad Corporate management

2 Unclear accountability, responsibility or delegation structure.

Unclear hierarchy/ Job description/appointment

3 Inadequate definitions of objectives and co-ordination of project and tasks.

Bad top management

4 Frequent reorganisation of departments. Bad top management

5 Too much bureaucracy and rigidity. Lack of leadership

S # Maintenance - Inadequate management of maintenance and repairs caused by:

Remarks

1 Inadequate planning, controlling, execution and recording of maintenance programmes.

Bad Corporate/project management

2 Shortage of maintenance personnel. Unclear policy 3 Financial or time constraints. Manage critically

S # Defences - Inadequate protection of employees and environment against

hazardous situations caused by:

Remarks

1 Lack of standardisation (lay out and displays) Bad Corporate management

2 Ergonomic consideration, human limitations e.g. size and strength of the individual.

Bad Corporate management

3 Inadequate communication between designs and end user, allowing substandard conditions to remain unchecked.

Lack of leadership

4 Financial and other constraints during design phase.

Bad top management

5 Poor discipline and enforcement. Lack of leadershipRoot causes listed above are general. These caused can be correctly, by employing professional engineers & managers, byhavingpragmatism, can chack & resolve all issues.

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It should be noted that these failures are generally, cummulative results of policy decisions and where possible, these should also, be checked for whatever actions taken to remedy such causes/ factors at corporate level.

d)“Detail any remedial action taken to date” Self explanatory, give brief details of what actions are being put in effect to prevent recurrence.All actions to remedy foregoing causes or impacts should be recorded in details & additional action necessary to be recommended or instructed should be included for resorting to further actions.All requirements shuld be clear in all respects, so that all instructions be self explanatory on reporting documents.

e) Priority action planDetail actions to be taken including procedure changes, training programmes etc. with dates for completion.In addition to general & specific actions required to be resorted to meet no further accidents state, immediate actions on priority basis required to be resorted to, should be ciculated immediately, without any delay, so that remidial procedures come into effect.

f)Investigation team Filled in by Site Safety Representative indicating personnel, who were included on investigation team & shall sign and date report. Report should be clear & precise & if so required, seminar or senior level talks could be planned for additional learning by all classes of personnel.

6.0 REFERENCESNone

7.0 ATTACHMENTS7.1 ‘Category A’ Reporting Form7.2 ‘Category B’ Incident Investigation Sheet7.3 Investigation Details

This form is completed in support of all ‘Category B’ reports by supervisor in charge of work being carried out. In this report, supervisor should identify personal version of facts regarding what happened onwork location, provide details of all pertinent information and give a brief statement on instruction given, including training brief or all information given, which relates to supervisor’s actions that may have a bearing on incident.

7.4 General Continuation SheetTo be used for either Category ‘A’ or ‘B’ report, providing witness statements, sketches, investigation comments or some other detail required in overall report

7.1 Category ‘A’ Reporting Form

INCIDENT REPORT #. CATEGORY 'A' REPORTS

DATE OF ACCIDENT \ \

Description of IncidentPersonal Injury

Property Damage

Near MissPotential severity Plant/Equipment involved Estimated CostActions taken to Prevent Recurrence M/F Home AddressSurnameFirst Name(s)Date of Birth \ \Nationality Tel No: Status: Single Marrried Details of EmploymentCompany NameCompany Address Spouses Name No.of Children Tel #. Hours on Shift that Day OccupationConsecutive Days Worked Experience Years MonthsBefore AccidentHow Long on Site Immediate SupervisorMedical DetailDescription of injury illnessPART OF BODY Head Eyes Neck Back TorsoAFFECTED Arm Wrist Hand Finger Internal

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Type of Incident

Type of Incident

Property Damage Report

Injury Report

7.2 Category ‘B’ Incident Investigation Sheet

INVESTIGATION DETAILS - CATEGORY "B"

INCIDENT REPORT NO: ____________________

COMPLETED BY SUPERVISOR

_________________ ___________________ ______________________ ___________________ Name Signature Job Title Company WEATHER CONDITIONS ON SITE LOCATION OF INCIDENT (I.E. AREA, UNIT, EQPT. #)_

DATE AND TIME OF INCIDENT

(dd/mm/yy) -------------------- Time ------------------(am/pm)

DATE AND TIME OF INVESTIGATION OF INCIDENT

(dd/mm/yy) -------------------- Time ------------------- (am/pm)DESCRIPTION OF INCIDENT

SITE INSPECTION AND INVESTIGATION DETAILS

SUPERVISOR STATEMENT

SIGNATURE:___________________________________

PROCEDURES/PERMITS IN OPERATION

a) ________________ __________________ _____________________ _________________________ NUMBER DATE ISSUED ISSUED BY WORK DESCRIPTION

b) _________________ _________________ _____________________ ________________________ NUMBER DATE ISSUED ISSUED BY WORK DESCRIPTION

7.3 Investigation Details

INVESTIGATION DETAILSINCIDENT REPORT # ____________________

COMPLETED BY SUPERVISOR _________________ ___________________ ______________________ ___________________ Name Signature Job Title Company WEATHER CONDITIONS ON SITE LOCATION OF INCIDENT (I.E. AREA, UNIT, EQPT. #.)_

DATE AND TIME OF INCIDENT

(dd/mm/yy) -------------------- Time ------------------(am/pm)

DATE AND TIME OF INVESTIGATION OF INCIDENT

(dd/mm/yy) -------------------- Time ------------------- (am/pm)

DESCRIPTION OF INCIDENT

SITE INSPECTION AND INVESTIGATION DETAILS

SUPERVISOR STATEMENTSIGNATURE:

PROCEDURES/PERMITS IN OPERATION a) NUMBER DATE ISSUED ISSUE BY WORK DESCRIPTION

B NUMBER DATE ISSUED ISSUE BY WORK DESCRIPTION

7.4 General Continuation Sheet

GENERAL CONTINUATION SHEET INCIDENT REPORT NO:

SUBJECT MATTER:__________________________________________________________________________

Date:

Please include any sketches/diagrams/etc that could be considered beneficial to the investigation

COMPLETED BY: NAME SIGNATURE COMPANY

Engineering

14 incident reporting