Accident-Incident Reporting Procedure

ACCIDENT-INCIDENT REPORTING PROCEDURE

Document Revision Status

Nnochiri Ogbonna
0 15.06.13

Michael Nnanna
GM-ENGINEERING SERV/ CORPORATE

HSE COORDINATOR

MD

Rev .

Date

Prepared

Reviewed

Approved

HAMMAKOPP CONSORTIUM LIMITED

HAMMAKOPP BASE Km 25 Onitsha Owerri Express Way Umuezedam Okija Anambra State. info@hammakoppconsortium.com

2013

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TABLE of CONTENTS

INTRODUCTION
1.1 1.2 1.3 1.4 1.5 2.0 3.0 General Objective of the Procedure Purpose of the Procedure. Definitions and Abbreviations. References Responsibilities Incident Reporting, Investigation & Communication 4.0 5.0 Emergency Contacts Emergency Flow Charts .

4
4 5 6 7 7 8 9 9 10 11 12 15 17-18

Purpose of an Effective Investigation Major Incident Notification Process Incident Potential Matrix

Immediate Incident Notification & Reporting Matrix

Attachments Attachment 1 Accident Reporting Form-Blank Copy Incident Notification Form Near-miss Reporting Form Detailed Incident Investigation Report Format 19-26

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REVISION HISTORY

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Revision R0

Date Page

Description

Approved

Accident - Incident Reporting Procedure.

INTRODUCTION General

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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 Accident 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;

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Like an iceberg, the unseen indirect costs of accidents are much larger than the direct costs 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 retraining, 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 and may 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 meet changes 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: PLANT/EQUIPMENT: PROCESS: AMENITY: GOODWILL: fatality, injury, illness damage, repairs, replacement interruption environment pollution 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 K. C AKUMA NNANNA MICHAEL CHUKWUNWIKE ALEX CHUKWUDUM IKENNA FEROZ JADOON JOITI KUMAR HUSSEIN MOHAMMED WILLIAMS OLATOYE NNOCHIRI OGBONNA ESIEKPE ISAAC HENRY IWUCHUKWU EWUZIE UCHE COKER MICHAEL OGBONNA FRANCIS MIRIAM IFEANYI JUDITH OKOLI ALEX ISOGIE SOLOMON DESIGNATION MD GM Engr & Corporate Services GM Projects Legal/SCD/Pro/Contracts Construction/Project Manager AGM - Maitenance Senior Site Engineer Engineering Coordinator HSE Coordinator HSE Supervisor Chief Security Officer Transport/Logistics Officer Asset Officer Site Nurse Base Nurse HR Officer HSE Officer-PH Base HSE Coord- Uyo Base PHONE 08033241099 08036719422 08033402965 08034727156 08037936436 08030896640 08160595035 08033150389 08036719585 07034547809 08038804602 08060824186 08034934641 08075790861 07065322241 08075790867 08158990940 08037534461

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Emergency Flow Chart

MEDICAL /EVACUATION EMERGENCY REPONSE FLOW CHART

Emergency Incident Observed at Site/Base/ Camp

Case Cannot be managed Internally

Call On-Scene HSE Co-ord, Site/Base managed Commandant Nurse will assess internally situation and take (OSC) action. GM. 08036719585/ 08036719422 07065322241 ,07028180801 or Code 1045 Case Cannot be managed
Internally Administer First Aid and Coordinate with Project Mgt. Team.
GM-Projects-08033402965
PM/CM-08037936436

Case Can be

Provide adequate First Aid or Med. Assistance.

Contact Client Site Rep.

Medevac + Evacuation Required? Hamakopp to initiate Evacuation . Stabilize

Coordinate with Evacuation/ MEDEVAC Provider

Access the Situation & report

Communicate MEDEVAC Provider If needed

Investigate &Report to Client 24hrs Contact Project Mgr to MEDVAC + Evacuate Victim

No need for MEDEVAC

Moves Victim to Hammakopp Retainer Clinic

Important Lines
MD-07028002304,08033241099 DPR-084-3290000 &084-4611777 FEMENV-08032557931. Retainer Clinic- Our Lady of Lourdes Ihiala 08135700630 Retainer Clinic- PH-Meridian: 08063572178 8063572178

Phone Lines
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- Abuloma, Site PH 08063487200----HSE OFFICER- Ichi Site, Anambra

Project Mgt. team to determine course of action

Inform MEDEVAC Provider

Investigate , Report & make Recommendations

Inform the Base Office

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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 Should 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.

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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 or contractors, 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

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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 made immediately 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 Number of persons Involved. Incident Severity. Major Serious Minor. 1 2 3 0 Level 2 Level 3 Level 3 1 Level 1 Level 2 Level 3 2-10 Level 1 Level 1 Level 2

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11+ Level 1 Level 1 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)

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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 MAJOR(within 2 hours) CONTACT. Phone / email Phone / verbal Phone / verbal / e-mail SERIOUS or Significant Near Miss(within 12 hours) MINOR or Near Miss(within 24 hours)

PERSON TO CALL:

BASE/ENGINEERING

Name ..............Michael Nnanna Mobile phone:..08036719422, 08075790844 PROJECTS CONTACT.

Name ................Alex Chukwunwike Mobile phone:....08033402965, 08075790845 MAINTENANCE CONTACT.

Phone / email

Phone / verbal

Phone / verbal / e-mail

Name ...................Joythi Kumar Mobile phone:................, 08075790872 LEGAL/SCD/PRO CONTACT.

Phone / email

Phone / verbal

Phone / verbal / e-mail

Name ...................Ikenna Chukwudum Mobile phone:................08034727156,08075790846 CONSTRUCTION CONTACT

Phone / email

Phone / verbal

Phone / verbal / e-mail

Name . .........................N.F.Jadoon Mobile phone.....................08075790847

Phone / email

Phone / verbal

Phone / verbal / e-mail

CONSTRUCTION PH BASE

CONTACT Phone / email Phone / verbal Phone / verbal / e-mail

Name . ..............Mohammed Hussain Mobile phone.........................08158990938 HSE CONTACT.

Name .................Nnochiri Ogbonna Mobile phone......08036719585, 08075790850 ASSET CONTACT.

Phone / email

Phone / verbal

Phone / verbal / e-mail

Name ...............Micheal Bayo Coker Mobile phone......08034934641, 08075790862 TRANSPORT CONTACT.

Phone / email

Phone / verbal

Phone / verbal / e-mail

Name ................Felix Ewuzie Uche Mobile phone......,............ 08075790852

Phone / email

Phone / verbal

Phone / verbal / e-mail

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HAMMAKOPP HSE PH BASE

CONTACT. Phone / email Phone / verbal Phone / verbal / e-mail

Name ..............................Alex Isogie Mobile phone.........................., 08158990940 HAMMAKOPP HSE UYO BASE CONTACT.

Name ..............................Solomon Mobile phone.........................., 08037534461 CSO CONTACT.

Phone / email

Phone / verbal

Phone / verbal / e-mail

Name ..................Iwuchukwu Hilary Mobile phone.........................., 08075790868 EMERGENCY RESPONSE TEAM Name . Isaac Esiekpe-08075790851. Name ..............Emmanuel Nworie-08063487200

Phone / email

Phone / verbal

Phone / verbal / e-mail

Phone / email

Phone / verbal

Phone / verbal / e-mail

CLINIC Name: Ogbonna Francis Name: Miriam Ifeanyi

CONTACT -08075790861 - 07065322241 Phone / email Phone / verbal Phone / verbal / 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:

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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

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PROJECT: ______________________________ LOCATION : ____________________ PLACE OF INCIDENT: ______________ DATE:_____________ TIME:______________ PERSONNEL INVOLVED INVOLVED 1. ----------------------------------------2. ----------------------------------------3. ----------------------------------------EQUIPMENT/MATERIAL 1. -----------------------------------------2. -----------------------------------------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:

Site:

Time:
Exact Location:

Activity:
Report Number:

Type
Anomaly Near Miss Incident

Damage Category
Human Loss Environmental loss Prod/Mat Loss Media Actual 1 - Minor 2Moderate 3 - Serious 4 - Major 5Catastrophic

Severity
Potential 1 - Minor 2 - Moderate 3 - Serious 4 - Major 5 - Catastrophic

Human Loss Classification

First Aid Medical Treatment Case Restricted Work Day Case Lost Time Injury Multiple Single

with estimated _Days Lost Illness Fatality

3 - Incident Information 3.1 - Human Loss/Injury & Victim Information (remove section if not used)
Name (s) Age Seniority date COMPANY Contractor or Third Party Job functi on Hrs since last sleep Hrs slept last time Hrs on duty Type of loss

1 2 3 4
Indicate details on injuries for each of the persons above

Injury

A H A Cut H Chemical Hea Fing B Heat Burn burn d ers C I B I Fracture/brea Sprain/strain 1 Fac Leg k J Bruise e s D Amputation K Crushing 2 C J E L Electrical Eye Ankl Concussion burn 3 s e F M Other D K Puncture/entr 4 Bac Feet y k L G Abrasion E Toe Medical Officer Name: _____________ Signature ______________ Trun s k M 3.2 Vehicle Incident Information (Remove section if not used) F Oth Arm ers Yes Was vehicle travelling in convoy : Yes No Was the driver the only occupant? s Was Vehicle Company Owned Rented/Leased Personal Vehicle On Company Business Yes G Han Weather Road Type Accident Type d

Body parts affected

Days lost (estimate d)

No No

Conditions

Dry Wet/slick Clear

Paved Off road Up a grade

Unpaved Curve Downgraded

Hit vehicle in front Hit from behind Backed into

Sideswipe Passing Being passed

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Dust Fog

Narrow

Poor surface

Hit stationary object Hit pedestrian Rollover

Hit & Run Hit animal Ran off road Measured __ hrs after event Yes Yes Yes No No No

Alcohol or drugs involved? (Testing required) Speed when accident occurred Driving monitor present and working? All persons wearing seatbelts?

Yes

No

Results of alcohol test _____ g/l Driving Certificate held? Charged by Police? Defensive Driving Training up to date?

______ km/h Yes Yes No No

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

Result
Vegetation damage Soil contamination Ground water contamination Release to water way Released to air Marine life damage Amount spilled or discharged: Material name or code : Duration of discharge: hrs Min

Details
Unit

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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) Ty pe : Description of loss Quanti ty Unit

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

Injury/Illness Costs ($000) Lost Work Days Temp Staff Medical Costs Litigation/O ther Total Remarks : Automotive Costs ($000) Replacement s Repairs 3rd Party Repairs Litigation/Oth er Total Environmental Costs ($000) Lost Products Remediation Litigation Other Total Other Costs ($000) Replacement s Repairs Lost Products Lost Revenue Total

5 - Investigation
Name of Manager leading the investigation: Names of other team members:

Investigation Section 5.1 - Immediate Causes (Key Words)

Contact/ Exposur N/A e Fall Struck by Caught between Explosion or burns Electrocution Drowning Vehicle incident Air transport incident Marine Transport incident Gas leak Liquid hydrocarbon leak Other

Investigation Section 5.2 - Immediate Causes (Practices & Conditions)

Unsafe Acts U Procedure Failing to secure plant Operating equip w/o authority Failure to follow procedure Failure to warn of inform Operating at improper speed performing hazardous lifting or loading Inadequate Guards or Barriers Inadequate PPE Defective Tools, Equip, or Mat. Congestion / Poor Access Inadequate Warning System Inadequate Illumination Material tools & equipment Using Under Influence of Incorrect/Defective Unsafe of Correct Tools / DrugsUse / Alcohol equipment Equip. equip in Servicing operation Failure to check equip Drug induced impairment Pressure exposure Slippery surface Defective Plant / Machinery /Equip. Wear and tear Radiation exposure Hazardous Atmospheric Conditions Unsafe Position / Posture Unsafe Loading / Lifting Horseplay Failure to Make Plant Safe Before UseMixing, Placing, Unsafe Combining Servicing equip in operation Substandard Housekeeping Corrosion / Slow Damage Excessive Noise or Temperature Inadequate Ventilation Safety devices inoperable

Unsafe Situation

Investigation Section 5.3 - Root Causes (Which of the following Human and/or Job Factors were the Basic Causes of this accident?)
Human Factors
Lack of knowledge Inadequate capability Inadequate Training Improper Motivation

Job Factors
Inadequate Leadership / Supervision Inadequate Engineering Inadequate Job Planning Inadequate tools, materials, equip.

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Stress Substance Abuse Lack of Awareness

Fatigue Inattention Lack of Sleep

Inadequate Purchasing Inadequate Work Instructions Procedures Inadequate Risk Assessment Inadequate Definition of Responsibilities

Inadequate Work Standards Inadequate Maintenance Inadequate Plant/Machinery/Equip. Abuse 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 below
Respect of laws & regulations Management Responsibilities Operational Responsibilities Risk Evaluation & Management Respect for the Environment Safeguarding of Health Contractors & Suppliers Competence & Training Emergency Preparedness Incident Analysis Audits & Inspections Performance Improvement Criminal act / ill will Other

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

Include in this section a summary of all the information collected during the investigation. Place supporting documents at the end of the report as Appendix. 1) 2) 3) 4) Winess Report Preliminary Incident Notification Investigation Report 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. Item No 1 2 3 Action Item Recommendation Person Responsi ble Target Date Complet ion. Date Remarks

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9 - Review and Endorsement

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Comments by Reviewing Manager

Endorsements

Reported By (Name): Noted By (Name): For HSE Division:

Signature: Signature: Signature:

Date: Date: Date: