PETRONAS TECHNICAL STANDARDS

HEALTH, SAFETY AND ENVIRONMENT

GUIDELINE

INCIDENT CLASSIFICATION, INVESTIGATION AND

REPORTING

PTS 60.0501
AUGUST 2010

2010 PETROLIAM NASIONAL BERHAD (PETRONAS)

All rights reserved. No part of this document may be reproduced, stored in a retrieval system or transmitted in
any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the
permission of the copyright owner.

PREFACE
PETRONAS Technical Standards (PTS) publications reflect the views, at the time of publication, of
PETRONAS OPUs/Divisions.
They are based on the experience acquired during the involvement with the design, construction,
operation and maintenance of processing units and facilities. Where appropriate they are based on, or
reference is made to, national and international standards and codes of practice.
The objective is to set the recommended standard for good technical practice to be applied by
PETRONAS' OPUs in oil and gas production facilities, refineries, gas processing plants, chemical
plants, marketing facilities or any other such facility, and thereby to achieve maximum technical and
economic benefit from standardization.
The information set forth in these publications is provided to users for their consideration and decision
to implement. This is of particular importance where PTS may not cover every requirement or diversity
of condition at each locality. The system of PTS is expected to be sufficiently flexible to allow
individual operating units to adapt the information set forth in PTS to their own environment and
requirements.
When Contractors or Manufacturers/Suppliers use PTS they shall be solely responsible for the quality
of work and the attainment of the required design and engineering standards. In particular, for those
requirements not specifically covered, it is expected of them to follow those design and engineering
practices which will achieve the same level of integrity as reflected in the PTS. If in doubt, the
Contractor or Manufacturer/Supplier shall, without detracting from his own responsibility, consult the
owner.
The right to use PTS rests with three categories of users:
1)
2)
3)

PETRONAS and its affiliates.

Other parties who are authorized to use PTS subject to appropriate contractual
arrangements.
Contractors/subcontractors and Manufacturers/Suppliers under a contract with users
referred to under 1) and 2) which requires that tenders for projects, materials supplied
or - generally - work performed on behalf of the said users comply with the relevant
standards.

Subject to any particular terms and conditions as may be set forth in specific agreements with users,
PETRONAS disclaims any liability of whatsoever nature for any damage (including injury or death)
suffered by any company or person whomsoever as a result of or in connection with the use,
application or implementation of any PTS, combination of PTS or any part thereof. The benefit of this
disclaimer shall inure in all respects to PETRONAS and/or any company affiliated to PETRONAS that
may issue PTS or require the use of PTS.
Without prejudice to any specific terms in respect of confidentiality under relevant contractual
arrangements, PTS shall not, without the prior written consent of PETRONAS, be disclosed by users
to any company or person whomsoever and the PTS shall be used exclusively for the purpose they
have been provided to the user. They shall be returned after use, including any copies which shall
only be made by users with the express prior written consent of PETRONAS.
The copyright of PTS vests in PETRONAS. Users shall arrange for PTS to be held in safe custody
and PETRONAS may at any time require information satisfactory to PETRONAS in order to ascertain
how users implement this requirement.

PTS 60.0501
AUGUST 2010

Acknowledgement
This document was jointly prepared with contribution from the following persons and their respective
organizations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.

Sulo Belawan
(Advisor)
Sazali Abu Kassim
(Lead)
Busari Jabar
W Idrus W Sabli
M Zainudin M Zain
M Jasbir Khan Abdullah
M Farizuddin Anwar Mansor
Ibrahim Hamid
A Hisham Mohamad
Ozair Saidin
Roselan Mohamad
Ahmad Tarmizi Jaafar
Rosnan Hamzah
M Hadzir M Said
Chee Tze Chian
Zukri Zainon
M Hazman Hamzah
Azharin Ahmad

GHSED
GHSED
GHSED
GHSED
GHSED
GHSED
GHSED
MLNG
PDB
PGB
PGB
PCSB
PCSB
PPMSB
MISC
CSD
CSD
CSD

PTS 60.0501
AUGUST 2010

TABLE OF CONTENTS
1.0

2.0

3.0

INTRODUCTION .................................................................................................................. 7
1.1

Objectives .................................................................................................................. 8

1.2

Structure of the Guide ............................................................................................... 9

1.3

Written Policy and Procedures ................................................................................. 9

SCOPE AND APPLICATIONS............................................................................................ 11

2.1

Reporting Company ................................................................................................ 11

2.2

References ............................................................................................................... 11

DEFINITIONS ..................................................................................................................... 11
3.1

Types and Categorization of Incidents ................................................................... 11

3.1.1
3.1.2

4.0

5.0

IMMEDIATE ACTION AND NOTIFICATION ....................................................................... 12

4.1

Online Incident Notification and Reporting ............................................................ 12

4.2

Immediate Action at Location ................................................................................. 12

4.3

Notification From Incident Location ....................................................................... 12

4.4

Initial Notification to the Group............................................................................... 13

4.5

Notification and Reporting to Authorities............................................................... 13

4.6

Submission of HSE Alert ......................................................................................... 14

THE INVESTIGATION ........................................................................................................ 14

5.1

General Principles and Requirements .................................................................... 14

5.2

The Investigation Process....................................................................................... 14

5.2.1
5.2.2

5.3

5.4

7.0

Notification ................................................................................................... 14
Immediate Corrective Actions ..................................................................... 15

Analysis of Investigation Findings ......................................................................... 18

5.3.1
5.3.2
5.3.3
5.3.4
5.3.5

6.0

Reportable Incident ...................................................................................... 11

Recordable Incident ..................................................................................... 12

Purpose ........................................................................................................ 18
Involvement of People ................................................................................. 18
Underlying Causes....................................................................................... 19
Recommendations ....................................................................................... 19
Consequence Management ......................................................................... 20

The Investigation Report ......................................................................................... 20

FOLLOW-UP ...................................................................................................................... 20
6.1

Communication of Lesson Learnt .......................................................................... 20

6.2

Implementation of Recommendations.................................................................... 21

6.3

Monitoring of Implementation ................................................................................. 21

6.4

Monthly Incidents Reporting ................................................................................... 21

INCIDENT ANALYSIS AND REPORTING .......................................................................... 22

PTS 60.0501
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7.1

Completion of Data Recording and Submission of KPIs ....................................... 22

7.2

Submission of Report and Performing of Statistical Analysis .............................. 22

APPENDIX 1: DEFINITIONS AND EXPLANATION OF TERMS...................................................... 23

APPENDIX 2: EXAMPLES AND INTERPRETATIONS ................................................................... 28
APPENDIX 3: INCIDENT CLASSIFICATION GUIDING PRINCIPLES, WORK RELATED AND
EXPOSURE HOURS EXAMPLES................................................................................................. 37
APPENDIX 4: MEDICAL TREATMENT CASES AND FIRST AID CASES ...................................... 40
APPENDIX 5: CLASSIFICATION OF OCCUPATIONAL ILLNESSES............................................. 41
APPENDIX 6: INCIDENT CLASSIFICATION CRITERIA ................................................................. 42
APPENDIX 7: INCIDENT INITIAL NOTIFICATION .......................................................................... 45
APPENDIX 8: INCIDENT DIRECT CAUSE CLASSIFICATIONS ..................................................... 47
APPENDIX 9: MONTHLY REPORTING .......................................................................................... 50
APPENDIX 10: HSE ALERT FORM ................................................................................................ 51
APPENDIX 11: THE INVESTIGATION PROCESS .......................................................................... 52
APPENDIX 12: INCIDENT INVESTIGATION TREES ...................................................................... 62
APPENDIX 13: BASIC RISK FACTOR (BRF) DEFINITIONS .......................................................... 66
APPENDIX 14: INCIDENT INVESTIGATION REPORTS & PRESENTATION MATERIAL
FORMAT

................................................................................................................................... 69

APPENDIX 15: INVESTIGATION OF NON ACCIDENTAL DEATH ................................................. 76

APPENDIX 16: SPECIAL SITUATIONS .......................................................................................... 77

PTS 60.0501
AUGUST 2010

1.0

INTRODUCTION
Monitoring is an essential part of a systematic approach to HSE Management. This document
provides guidance on the reporting of incidents, in order to be able to set targets for
improvement and measure, appraise and report performance in pursuance of the goal to
protect the environment, cause no harm to people, and protect asset.
This document is a result of combining two PTS documents namely:

PTS 60.0504 Incident Classification and Reporting (Guideline) Rev1 June 2006
PTS 60.0501 Incident Investigation (Guideline) Rev 1 June 2006,

and will carry the number PTS 60.0501

This document defines which incidents are to be reported to the PETRONAS Group Service
Companies and authorities and when. It also provides guidance on internal reporting within
OPU/JV/HCU companies, the investigation, and the documentation.
The guiding principles for incident reporting are that:

management controls should be in place for activities and operations having the
potential for incidents with a significant impact on the company

incidents in such activities and operations are reported and included in the statistics
as a means of measuring the effectiveness of these management controls

Significant impact in this context refers to incidents with a consequence rating 3 to 5 in the
Incident Classification Criteria Matrix.
It should be recognised that guidance on incident reporting is not, and cannot be, definitive
for all situations as stakeholder perceptions, expectations and requirements vary from one
country to another and change continuously.
The scope of this guidance is the classification and reporting of incidents resulting in injury
or illness and/or damage (loss) to assets, the environment, reputation or security. New
requirements on incident notification and reporting are added to improve on the
categorization and analysis.
This document also provides guidelines on procedures for effective incident investigation and
analysis.
There has been a tendency in incident investigation to address only specific occurrences
which had actual outcomes and/or large consequences. The new approach presented in this
guide puts emphasis on those incidents with the potential for serious injury, illness, damage or
loss. Every incident should be investigated, although the seniority of investigators and the
degree of detail of the investigation may vary and should depend on the actual and potential
consequences of the incident. The document explains the level of investigations to be
conducted internally within OPU/JV/HCUs and by PETRONAS Group HSE Division.
The primary purpose of incident investigation is to prevent recurrence of similar incidents by
identifying deficiencies and recommending remedial actions. Follow-up should ensure that
those actions are implemented. Statistical analysis of the results of incident reports can
enhance the learning effect of each individual case by deriving trends. These can be used to
identify and correct Health, Safety and Environmental (HSE) management weaknesses, as
well as activity and hardware deficiencies in a Company's operations.
Studies have shown that incidents can have many causal factors and that underlying causes
often exist away from the site of the incident. Proper identification of such causes requires
timely and methodical investigation, going beyond the immediate evidence and looking for
underlying conditions which may cause future incidents. Incident investigation should

PTS 60.0501
AUGUST 2010

therefore be seen as a means to identify not only immediate causes leading to, but also
failures / omissions in the management of the operation.
Management must support, be involved in investigations and prepared to act on investigation
findings.
Lessons learned from incidents that are potentially of benefit to others should be
communicated throughout the Company and within PETRONAS Group. Consideration should
be given to communicate such lessons to other interested parties as appropriate.
OPU/JV/HCUs and PETRONAS Group HSE Division are required to conduct periodical
analysis of the incidents so that common issues within the OPU/JV/HCUs and/or Group can
be rectified immediately.
1.1

Objectives

The objectives of this Guide are:

to provide a consistent requirements for OPU/JV/HCUs to classify and report incidents.

to provide line managers, HSE advisors and contractor managers with a consistent
approach to incident investigation in order to achieve a high quality of reporting and
analysis,

to explain the incident investigation process and the relationship between the available
techniques and methodologies for analysis and recording,

to provide a basis for developing Company specific investigation procedures and

guidelines.

PTS 60.0501
AUGUST 2010

1.2

Structure of the Guide

The main text of the Guide describes all the steps to be taken after an Incident has occurred.
These are summarised in Figure 1. The incident notification and reporting timeline is
summarized in Table 1.
Further details of the investigation process, techniques and methodologies, as relevant for the
investigator or investigation team are presented in Appendix 11, 12 and 14. The Basic Risk
Factor definitions are given in Appendix 13. Special investigations are given in Appendix 15
and 16. A list of definitions is given in Section 3 and further described in Appendix 1.
The examples, classifications and reporting requirements are described in Appendix 2 to
Appendix 10.
1.3

Written Policy and Procedures

An essential requirement for management of HSE is to have a written policy and procedures
for incident investigation. These should be available to all employees and should require
reporting, recording and investigation of all incidents which result in the following:

Work Injuries

Occupational Illnesses

Environmental Damage

Property Damage

Near Misses

Security Breach

The procedure should specify the actions required at each stage in the investigation process
and indicate the action parties, routing of communications and reports, and related deadlines.
The procedures should be supplemented by guidelines on a number of issues, including the
following:

classification and reporting

preservation of evidence including condition and position of equipment, supervisory

instructions, work permits, recording charts, etc.

formation of investigation teams

assessment of incident potential

HSE, drugs and alcohol policy

evaluation of emergency response, rescue activities and damage control measures

training in incident investigation

awareness that reports may be required by third parties such as national authorities,
legal bodies, etc.

PTS 60.0501
AUGUST 2010

Figure 1: Incident Classification, Investigation and Reporting Flow Chart

Table 1: Incident Notification and Reporting Timeline Summary

Required Documentation from OPU
Incident Notification
(Minor: Rating 1 & 2)

Duration
Within 24 hours after incident

Incident Notification
(Minor: Rating 3)
Within 24 hours after incident

Incident Notification
(Major: Rating 4 & 5)
Within 1 hour after incident

HSE Alert
(Major Incident)
Lesson Learnt
(Major Incident)
Final Investigation Report
(Major Incident
Follow-Up Report
(Fatal Incident)
Monthly Incident (Summary)
Reporting

To Who
OPU/JV/HCU internal
management

Authority (if required)

COMCEN

Head GHSED

Respective VP

OPU/JV/HCU internal
management

Authority

All of the above

Presidents Office

EVPs Office

Country Manager

VP Legal

SGM Corporate Services

(Corporate Affair)
OPU to GHSED. GHSED to
disseminate to other OPUs/JVs/HCUs

Within 2 days after incident

1 week after completion of incident
investigation
1 month after completion of incident
investigation
1 year after the incident
th

By 10 day of each month

10

OPU to GHSED. GHSED to

disseminate to other OPUs/JVs/HCUs
OPU to GHSED
OPU to GHSED
OPU to GHSED

PTS 60.0501

SCOPE AND APPLICATIONS

2.1

Reporting Company

This document applies to those Companies/Joint Ventures/Holding Company Units where the
PETRONAS has full authority to introduce and implement:

PTS 60.0101 Group HSE Management Systems Manual.

It also applies to those Companies/Joint Ventures/Holding Company Units which have agreed
to report performance data to the Group.
These organisations are subsequently referred to as OPU/JV/HCU.
Individual queries about the application of this guide should be addressed to the relevant
Business Organisation.
External HSE Reports will draw on data reported by OPU/JV/HCUs under this guidance and
may be subjected to independent verification. For fatalities, in line with the practice adopted
by other major oil companies, data given in external reports will usually only include
OPU/JV/HCU and Contractor employees and not third parties.
2.2

References

This document makes some references to other documents such as:

2.0

PTS 60.0112 Group Contingency Planning Standard 2008

PTS 60.0503 Tripod-Beta The Analytical Tool (Guideline) Rev1 June 2006

DEFINITIONS
3.1

Types and Categorization of Incidents

All incidents will be classified either as Reportable or Recordable. The major difference
between these two categories is the element of span of control. Reportable Incident is one
where management has the influence to put controls in place, whereas Recordable Incident is
one where management has no influence over the controls that are put in place. The
definitions for Reportable and Recordable Incidents are as follows (and further explained in
Appendix 3):

3.1.1

Reportable Incident

A Reportable Incident is one that has caused injury to personnel/contractor/third party and/or
damage to company property and/or pollution to environment and hence is required to be
reported to the Group. The incident is included in companys statistics. The incident involves
the following criteria:
i)

Work-related activities carried out by company/contractor/third party personnel on

company premise and/or outside company premise, where exposure hours are
accumulated, and /or;

ii)

Span of Control. The company has full controlling influence to implement controls at
location and monitor effectiveness, and/or;

iii) Time of incident. The incident occurs during working hours including lunch hours,
overtime and traveling, and/or;
iv) Non-work related activities but inside company premise which has caused injury to

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PTS 60.0501
AUGUST 2010

personnel/contractor/third party or damage to property due to negligence, error or

omission on the part of company.
3.1.2

Recordable Incident

Recordable Incident is one where both the managements span of control and exposure hours
accumulation are missing. The incident occurs not under the control of the company or its
contractor while undertaking work-related activities. It is also incident of non-work related
activities either inside or outside company premise which cause injury or damage to property
but not due to negligence, error or omission on the part of company or personnel. The
incident is not included in companys statistics.
The above definitions and other definitions can be found in Appendix 1 and the examples are
given in Appendix 2.
In addition to classifying each incident either as Reportable or Recordable, each incident
should also be determined its Incident Direct Cause which is defined as an event or failure
that led directly to the incident, without any additional intervening action or failure. The list of
Incident Direct Cause is given in Appendix 8.
3.0

IMMEDIATE ACTION AND NOTIFICATION

4.1

Online Incident Notification and Reporting

Under PETRONAS iHSE database, there is a module on Incident Notification and

Investigation System for online notification and submission of investigation reports.
OPU/JV/HCU shall utilize the iHSE database to notify incident, create HSE Alert, capture
investigation reports and create Lessons Learnt on incidents.
4.2

Immediate Action at Location

When an incident occurs the first action to be taken is to prevent further injury and arrange for
any necessary medical treatment as well as taking measures to prevent the situation from
escalating and causing further damage. Where possible, the site should be left unchanged
until the investigation team has inspected it. Where this is not possible, photographs should
be taken or sketches be made of the scene.
A preliminary assessment of the incident should be made to identify the extent of injury or
damage, and any potential for escalation.
4.3

Notification From Incident Location

After arranging any necessary first aid and medical treatment and taking measures to prevent
consequential losses and injuries, notification from the location of an incident is made in order
to:

advise operations control (so that adjustment can be made to the plan of operations)

facilitate notification to other parties as required

initiate the investigation process.

Notification should be made via the senior person at the location or plant. Notification should
be routed to the line function and to other departments from which assistance is sought and
also to the HSE organisation. Routing should be specified in the Company's Incident
Investigation Procedures. The notification should contain details of:

time, place, nature and direct cause of the Incident

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PTS 60.0501
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Classification of reportable or recordable incident

persons injured/equipment damaged

nature of injury/damage and estimate of severity (which rating in the Incident

Classification Criteria Matrix)

immediate corrective action being taken

assistance required

operation in progress at the time.

The notification report should be factual and avoid hearsay, assumptions and preliminary
conclusions. If the notification is made verbally via mobile phones, it should be followed up by
a written email, faxed or telexed confirmation.
Operating companies should set stringent, fast, but achievable deadlines for notification to
allow prompt initiation of the investigation process. All incidents should be communicated
internally within 24 hours or other practical time.
4.4

Initial Notification to the Group

Rating 3 to Rating 5 incidents as per Incident Classification Matrix (Appendix 6) are regarded
as Major Incidents and the Initial Notification should be reported immediately as per the
guidelines in Appendix 7. Rating 3 incidents should be reported within 24 hours, whereas
Rating 4 and 5 incidents should be reported within 1 hour to the relevant Group Services by
using the standard form as given in Appendix 7. Notwithstanding of the above, any incidents
that activate Tier 2 and Tier 3 of Emergency Response should be reported within 1 hour. The
relevant units in the Group to be notified are:
- President Office
- Business Head (Executive Vice President)
- Respective Vice President
- Country Manager for International Operation
- Head, Group HSE Division
- VP Legal
- Senior General Manager Corporate Services / Corporate Affairs
- COMCEN
In assigning the rating or severity of the incident for the purpose of the above initial
notification, Group HSE Division should be consulted.
When there is incident that requires Initial Notification, the OPU/JV/HCUs should submit the
notification to COMCEN and Business Head. COMCEN shall take the responsibility to notify
the other relevant parties immediately.
The responsibility for reporting incidents lies with the Company accumulating the exposure
hours. In the case that hours are not accumulated e.g. for third parties and environmental
incidents, the Company employing the personnel involved, or responsible for operating the
equipment or facilities involved is responsible for reporting.
4.5

Notification and Reporting to Authorities

There may be a requirement for local or national authorities to be notified of all incidents in
certain categories (e.g. in Malaysia, fatalities will involve both the local Police and Department
of Occupational Safety and Health (DOSH), occupational illnesses and those accidents
involving lifting appliances, pressure vessels requires notification to DOSH or motor vehicles
to the local Police, and any environmental incident to Department of Environment).

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4.6

Submission of HSE Alert

The HSE Alert of all incidents of Rating 3 to 5 should be prepared by OPU/JV/HCUs and
submitted to Group HSE Division by using the form in Appendix 10. The submission should
be made within 2 days after the incident. Group HSE Division should review the submission,
assign a Reference Number and disseminate the HSE Alert to other OPU/JV/HCUs.
The requirements for classifying, notifying, recording, reporting, initiating investigation and
conducting analysis are defined and included in the Group iHSE under Incident Investigation
and Reporting Module.
5.0

THE INVESTIGATION

5.1

General Principles and Requirements

5.1.1

All incidents which fall under the scope of this PTS shall be investigated.
(Note: To ensure this is achievable, it is important that incident notification
and reporting requirements as specified in Section 4 are fully complied with)

5.1.2

Investigations should be carried out as soon as possible after the accident.

As the quality of evidence can deteriorate rapidly with time, any delayed
investigations are usually not as conclusive as those performed with
dispatch.

5.1.3

The purposes of accident investigation should be aimed towards identification

of the root causes of accidents so that actions can be taken to prevent
recurrence. Both actual and potential impacts should be identified. It may
reveal the deficiency in HSE Management.

5.1.4

The responsibility for carrying out incident investigation lies with the owner of
the asset or operations involved in the incident.

5.2

The Investigation Process

5.2.1

Notification
a.

After arranging first aid and medical treatment and taking measures to
prevent consequential losses and injuries, notification from the location of an
accident shall be made. To ensure sufficient information is available for
incident investigation planning purposes, incident notification should contain
details on:

b.

operation in progress at the time

time, place and nature of accident
persons injured/equipment damaged
nature of injury/damage and estimate of severity
immediate corrective action being taken
assistance required.

Notification of incident within the OPU/JV/HCU should be made by the senior

supervisor at the location or plant; notification of road transport accidents
away from company premises should be made by the driver involved. To
ensure incident investigation can be initiated timely, OPU/JV/HCU shall
establish effective routes and means of communication.

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c.

5.2.2

To initiate the investigation for Major Incident, Terms of Reference shall be

established.

Immediate Corrective Actions

Corrective actions shall be carried out to make the incident site safe and does not
endanger other personnel or the plant. However as much as possible, OPU/JV/HCUs
should keep the site 'as is' until at least a preliminary investigation has taken place.
It may be necessary to clear the area or rectify problem in order to minimize the
consequence, eliminate the hazards or facilitate emergency response operations. In
such cases, photographs of the sites should be taken and relevant evidences
preserved.
Local legislation may prescribe that for certain classes of accident, e.g. fatality or
motor vehicle accident, nothing may be moved without prior permission from
authorized persons.

5.2.3

Investigation Team
a.

General

The size and composition of an investigation team should depend on factors such
as:

the extent of actual or potential injury or damage

the potential for repetition
the departments involved
requirements for specialist knowledge
legal requirements

In this context the investigation of a Near Miss with serious incident potential may
demand more resources and expertise than some incidents which have actually
resulted in damage or injury. For the minor incidents, collection and analysis of
repetitive cases provide measures of improvement.
Investigation must be done by trained team members, or at least trained team
leader, by using proven tools, methodology and procedures. Independencies of
investigation should be observed. This can be done by having the Investigation
Team led by unaffected department. Multi-expertise team members are
recommended, for example for OH cases, OH Doctor may become one of the
investigation team members.
Following the concept of line responsibility for safety, the line should take the lead in
incident investigation.
When the Terms of Reference is established, the Investigation Team should adhere
to the document.
b.

Contractor Incidents

The general principles and requirements on incident investigation as specified in

Section 5.1 is also applicable for all incidents involving contractors operations or
personnel which occur on PETRONAS premises or involves PETRONAS property or
interests.

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PTS 60.0501
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c.

Investigation by Local or National Authorities

In the event that local authorities take over responsibility for the investigation,
OPU/JV/HCU should nominate a focal point to liaise with the authorities and to
assist them in assembling the information they require.
Notwithstanding the involvement of the authorities, OPU/JV/HCU should carry out
their own investigation into the accident. Where relevant to a proper understanding
of the accident, the Company should endeavour to obtain from the authorities any
evidence, such as copies of (police) reports.
For detail, please refer to Appendix II Section 2.0
5.2.4

Facts Finding Process

a.

General

In carrying out investigation, the team should collect as many facts as possible
which may help understanding of the incident and the events surrounding it. The
main sources of information are:

observations at the scene of the incident

interviews
written instructions and procedures
records
reports of specialist investigations

It may sometimes be appropriate to obtain background information before visiting the

incident site. For example:

general procedures for the type of operation involved

records of instructions/briefings given on the particular job being investigated
location plans
command structure and persons involved.

Checklists may be used in the early stages if the investigation to keep the full range
of enquiry in mind. When checklists are used, their limitations should be clearly
understood.
b.

Site Inspection

Important evidence can be gained from observations made at the scene of the
incident, particularly if equipment remains as it was at the time of the incident.
Witnesses' statements can usually be better understood and verified if discussed at
site.
Photographs and/or video film may be taken during site visit. In the absence of
photographs or films, sketches or graphical illustrations of the site layout or
equipment could be made. While photographs and diagrams can be used in the
incident analysis and/or as attachments in the investigation report, video films may
be used later for HSE communication or training purposes.
During site visit, the investigators should look for any conditions in the immediate
environment which could have contributed to the incident. Examples of items to
check include:

the position of all equipment in relation to other equipment/facilities

the position of valves, spades, set points, recorders, override switches etc.

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PTS 60.0501
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c.

the condition of the load-bearing surface

accessibility/evidence of congestion
illumination of the location/site
state of housekeeping
the condition of all equipment/facilities
presence (absence) of warning signs/notices
effects of weather
presence of witnesses
evidence of spills or release
odours, discolouration
presence of unauthorised people - evidence of excessive forces

Interview

Interview shall be carried out at earliest time possible in order to be able to capture
initial knowledge of each witness before lapse of times.
The following should be consider in planning for an interview

Prioritize the persons to be interviewed, starting from the victim(s) or

personnel directly involved in the incident and followed by witnesses and
other personnel such as the work supervisors, colleagues and management
personnel.

Appropriate interviewer should be selected taking into consideration the

subject matters to be checked, areas of expertise, level in the
organizational hierarchy and personality of the individual

Proper scheduling interviews to ensure availability of interviewer

Specific checklists may be developed to facilitate in the interviewing

process

The following Guidelines should be used when conducting an interview

Interview should be carried out at appropriate and conducive location,

preferably in the interviewees room, work place or at the incident site. If the
interviewee is the injured person, it may be necessary to interview him at the
hospital or at his home if the interviewee is undergoing medical treatment at
the hospital or taking rest the home.

Interviews should be carried out individually so that interviewees are not

influenced by each other

Witnesses should be asked to go step-by-step through the events

surrounding the accident, describing both their own actions and the actions of
others. In order to ensure that all the facts are uncovered, the open and
broad questions of "what?, why?, when?, how?, where? and who?" should be
utilised.

The value of a witness's statement can be greatly influenced by the style i.e.
personality/character, language, job position of the interviewer, whose main
task is to listen to the witness's story and not to influence him/her by making
comments or asking leading questions.

Great care should be taken not to make an interviewee feels intimidated by

too many interviewers

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Maintain confidentiality of the interviews

At the end of an interview the discussion should be summarized to make sure that no
misunderstandings exist. Any anomalies in the statement or conflict with other
evidence should be discussed, the interviewee being invited to clarify points as
necessary.
In particular it should be noted that the statements made by different witnesses may
conflict, and supporting evidence may be needed.
d.

Documents Review

Relevant documents should be reviewed as they could serve as evidences or could

provide information which may lead to identification of directs or underlying causes of
the incident. Such documents may be available in the form records such as "as-built"
drawings, instrument and tachograph records, print-outs, log sheets/books,
maintenance records, work permits, load and time sheets.
Written instructions and procedures may provide information to the investigation team
on work processes and parties involved in the activities.
The investigation should try to establish the extent to which written procedures and
instructions were understood and acted upon, as these can indicate the effectiveness
of training and supervision.
e.

Incident Investigation Trees

During the fact finding stage, incident investigation tree may be constructed to show
the connections between the various possible events and conditions leading to the
incident. Appropriate incident investigation diagram based on established incident
causation model e.g. fault tree diagram, cause and effect diagram etc may be used.

5.3

Analysis of Investigation Findings

5.3.1

Purpose

The purpose of analysing is to establish the sequences of critical events and the underlying
causes of the incident and of its consequences.
Note: Analysis of a group of incidents can highlight patterns or trends in types of incidents or
incident causes, so that safety efforts can be focussed on recurring causal factors or
recognisable hazard areas.
5.3.2

Involvement of People

It is almost inevitable that the actions or omissions of people are found among the causal
factors.
A common reaction to this is for the investigation process to lean towards a 'blame' culture,
typified by punishment featuring prominently in the recommended actions. The blame culture
acts against the prime objectives of investigation by inhibiting the frankness which is
necessary during fact finding. Errors of professional judgement should be viewed in the
context of the discretion and initiative that is normally expected.
An organisation must be prepared to question its own philosophies, standards and
management style to ensure that it has not created a culture which invites or conditions its
personnel to cut comers or take chances.

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5.3.3

Underlying Causes

The investigation of incidents beyond the immediate and most obvious causes calls for a
broad approach. During the analysis it will be necessary to look in more detail at areas such
as:

company policy
managerial practices
operating philosophies and procedures
engineering design
equipment selection
work planning
job descriptions and responsibilities
organisational relationships
control systems
qualifications and experience criteria
training methods
working/duty hours policies and practices
safety auditing
contract conditions and controls
maintenance procedures and records
testing methods and records
methods of instruction and communication
operator perceptions.

Existing policies and procedures may have had elements or omissions which, combined with
other causal factors, have contributed to the incident.
Effective investigation needs to seek the 'causes behind the causes' (i.e. defects in the
systems for planning, controlling and executing the work). This can involve selfcriticism,
and/or the challenging of systems, procedures, policies or even cultural norms which have
been accepted hitherto. Where deficiencies are highlighted, the analysis process should look
into why they were not detected and corrected before the incident (i.e. shortcomings in
management).
Investigations can open up a wide range of causal factors, many of them linked together in
their contribution to a particular incident. Even if all causes cannot be addressed at once,
removal of some critical links will significantly reduce the probability of such incidents
recurring.
Systematic investigation should ensure that possible causes are considered in both the range
and depth appropriate to the incident. In addition to the causes of the initial event, causes of
consequential injury or damage should be examined, as these may also highlight inherent
deficiencies.
Any assumptions made during the analysis should be clearly identified in the report, as they
are open to challenge.
5.3.4

Recommendations

The ultimate objective of the investigation process is to identify action to prevent recurrence.
Not all causes can be completely eliminated, and some may be eliminated only at prohibitive
cost.
Some recommendations will therefore be aimed at reducing a risk to an acceptable level,
while others will be aimed at improving protective systems to limit the consequences.

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All recommendations should be in the form of practical action items. They should identify the
action party, so that effective follow-up can be achieved. Deadlines for action can be
suggested for subsequent endorsement by the action party.
Recommendations relating to procedures or the quality of supervision or training have the
following advantages:
the solutions lie with the people in the incident environment
they can usually be implemented quickly
implementation can usually be achieved with little or no additional costs.
Modifications to facilities, additional equipment or other 'hardware' solutions are appropriate in
many cases, but they can have disadvantages:
they may avoid more fundamental and difficult 'people' issues relating to
management, supervision and training,
they are sometimes used as an attempt to buy a way out of a problem rather than to
'think' a way out,
they require funds, and therefore the onus for providing a solution is passed to
someone else, i.e higher management,
they can take more time to implement,
they may create other problems, e.g maintenance, or access.
When considering possible corrective actions the following factors should be borne in mind:

effectiveness, practicability,urgency/implementation time, permanency, extent or

breadth of benefit. Where an investigation highlights deficiencies not related to the
incident, a separate report and recommendations should be made.

Cases of extreme negligence or blatant disregard for established safe practices may indicate
the need for disciplinary measures. At the review stage, the specific measures considered
appropriate should be confirmed. If there are alternative recommendations, the preferred one
should be indicated. In the event that a recommendation will take a long time to implement,
interim measures should be suggested. To prevent a single factor (e.g. metallurgic testing)
holding up the reporting, a recommendation could be to investigate further in that specific
area.
Group HSE Division should be consulted on any findings of the analysis and
recommendations.
5.3.5

Consequence Management

Incident investigation findings shall address elements of negligence or failure of individual(s)

or party(ies) in discharging their roles and responsibilities which had contributed to the
incident. Consequence management actions e.g. show cause letter or other appropriate
disciplinary actions which have been or need to be taken shall be included in the investigation
report.
5.4

The Investigation Report

The investigation report is a presentation of the findings and recommendations of the

investigation team. The report should be in a standard format (see Appendix 14).
Before distribution the investigation report should be reviewed at the appropriate
management level, as a check on the completeness of the investigation and for endorsement
of the recommended actions.
6.0

FOLLOW-UP
6.1

Communication of Lesson Learnt

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To maximise the lessons learnt, relevant findings and conclusions of incident investigations
should be given as wide a distribution as practicable.
The lessons learnt of all incidents of Rating 3 to 5 should be prepared by OPU/JV/HCU and
submitted to Group HSE Division within one week after the completion of Incident
Investigation. Group HSE Division should review the submission, assign Reference Number
and disseminate the lessons learnt to other OPU/JV/HCUs.
Discussions at, and feedback from, HSE meetings and team briefings should be used to
maximise the benefits from the learning points of the incident investigation and help achieve
the objective of preventing of similar incidents.
Learning points which may have a wider industry value may be exchanged with industry
contacts, safety institutes, etc.
6.2

Implementation of Recommendations

Recommendations should be discussed on a formal basis with action parties for agreement
on the action required and the time-schedule for implementation. This should be reviewed
and endorsed by OPU/JV/HCU management.
6.3

Monitoring of Implementation

Much of the value of incident investigation will be lost if the implementation of agreed
recommendations is not achieved. Where recommendations cannot be fully implemented
immediately, a formal follow-up monitoring system is required to ensure that agreed actions
are implemented and/or non-conformances are known to management and formally
endorsed.
Hardware related items are normally easy to identify as having been completed, e.g. when
the modification has been effected or when the new equipment has been received or
installed. This is not always the case with items such as training, changes to procedures or
supervision and particularly when action is described as "ongoing". A precise description of
the action item is essential if it is to be effective.
It is suggested that a procedural action point is considered to have been completed when:

approved written instructions have been issued and circulated to all staff concerned
when the changes in procedures have been monitored and found to be effective.

It will be necessary to set a deadline to ensure implementation of recommendations. The

schedule for implementation should take both of these progresses into account.
Items involving training or changes in supervision should be handled in a way similar to
procedures. The changes must be planned, circulated as necessary, and monitored until they
are seen to have taken effect.
The quality of incident investigation and the effectiveness of the solutions implemented should
be audited on a routine basis. If there are shortcomings they should be tackled by training
programmes or other techniques.
Note: The Group reporting procedure for fatal accidents requires a follow-up report to be
made one year after the accident, reviewing actions taken and assessing their results.
Details as per Appendix 11.
6.4

Monthly Incidents Reporting

Each OPU/JV/HCU should report the summary of incidents monthly to Group HSE Division

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for consolidation and reporting to higher management. The summary report should follow the
th
form as per Appendix 9 and should be submitted to Group HSE Division by 10 day of each
month. The same requirement should be reflected in the iHSE system.
7.0

INCIDENT ANALYSIS AND REPORTING

7.1

Completion of Data Recording and Submission of KPIs

After completing the investigation, the data in the initial notification and HSE Alert should be
updated accordingly to the final findings from the investigation. This should be apparent when
using iHSE system. The KPIs should be reported on monthly basis to Group HSE Division.
7.2

Submission of Report and Performing of Statistical Analysis

The current statistical analysis of incidents might have focused mainly on trend monitoring of
injury and incident frequencies in terms of actual consequences. Identified trends were used
to set future targets.
With the improved PTS and introduction of iHSE, the scope, range and quality of statistical
analyses can be increased e.g. by incident classification and recording in terms of:

direct cause
reportable and recordable incidents
underlying causes or root causes (by use of the 11 Tripod General Failure Types /
Basic Risk Factors).

This analysis allows for better identification of the lessons learnt from individual incidents and
improves the ability to identify and correct weaknesses in HSE management. In addition, it
can also facilitate performance monitoring of individual units, contractors, etc.
Statistical analysis of incidents is only able to reflect what has happened and is therefore a
reflection of past policies and their implementation. For statistical analysis to be meaningful a
significant number of entries is required in order to be able to detect trends. As a company's
safety performance improves, complete recording and analysis of all incidents becomes
increasingly more important.
In order to give flexibility for OPU/JV/HCU to conduct investigation, OPU/JV/HCU may use
various investigation tools to complete their investigation. For MAJOR incidents, however, the
use of Tripod Beta tool is very much encouraged and recommended.
To ensure consistent analysis is conducted and common root causes are identified, the final
investigation findings should be consistently reported by using the same 11 Tripod Basic Risk
Factors for the categorization of the root causes. This is to ensure analysis is conducted of
the same spectrum. If investigation tools other than Tripod Beta is used, the root causes need
to be aligned to the 11 Tripod Basic Risk Factors.
The final investigation report for MAJOR incident should be submitted to Group HSE Division
no later than 1 month after the completion of the investigation. If confidentiality is an issue, a
summary report should be prepared and submitted within the same timeframe mentioned
above. The summary report should contain the following:
- Summary
- Brief Introduction (describing the incident including type of incident, type of injury, phase of
operation or activity, cause of incident, and direct cause category)
- Root Causes (in the forms of Tripod Beta BRF).
- Conclusion and Recommendations
- Lessons Learnt

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APPENDIX 1: DEFINITIONS AND EXPLANATION OF TERMS

ACCIDENT
An Accident is an Incident which has resulted in actual Injury or Illness and/or Damage (Loss) to
Assets, the Environment or Third Party(ies).
CONTRACTOR
Contractors include all parties working for the reporting OPU/JV/HCU either as a direct Contractor, or
as a sub-contractor.
EMPLOYMENT
Employment means all work or activity performed in carrying out an assignment or request of a
Reporting Company or Reportable Contractor, including related activities not specifically covered by
the assignment or request.
Employment also includes activities, even outside working hours, where the Reporting Company has
the Prevailing Influence. Under certain circumstances travel to and from work is also considered as
being in the course of Employment.
EXPOSURE HOURS
Exposure hours are the total number of hours worked including overtime and training but excluding
leave, sickness and other absences. The exposure hours should be reported separately for
OPU/JV/HCU and Contractor personnel.
A meaningful assessment of incident data requires the number of exposure hours of work related
activities of OPU/JV/HCU personnel and Contractors to be accumulated. Guidance on the number of
exposure hours to be accumulated is given in Appendix 3.
Contractor activities that are excluded by the OPU/JV/HCU for reporting - on the basis of risk
considerations - shall not accumulate exposure hours.
Time off-duty, even if this time is spent on OPU/JV/HCU premises, is not accumulated for the
calculation of exposure hours although incidents during this time shall be included if they are the
result of failure or absence of management controls.
FATAL ACCIDENT RATE (FAR)
The Fatal Accident Rate is the number of work-related Fatalities per 100 million exposure hours.
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 flames,
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 CASE (FAC)
Any one-time treatment and subsequent observation of minor scratches, cuts, burns, splinters, etc.,
which do not ordinarily require medical care by a physician. Such treatment and observation are
considered First Aid even if provided by a physician or registered professional personnel. Examples of
FACs are to be found in Appendix 4.
INCIDENT
An Incident is an unplanned event or chain of events, which has, or could have caused injury or

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illness and/or damage (loss) to people, assets, the environment, reputation, or third party(ies). Any
injury such as a cut, fracture, sprain, amputation etc, which results from a single instantaneous
exposure.
INCIDENT DIRECT CAUSE
An event or failure that led directly to the incident, without any additional intervening action or failure.
LOST TIME INJURIES (LTIS)
Lost Time Injuries are the sum of Fatalities, Permanent Total Disabilities and Lost Workday Cases but
excluding Restricted Work Cases.
LOST TIME INJURY FREQUENCY (LTIF)
The Lost Time Injury Frequency is the number of Lost Time Injuries per million exposure hours.
LOST WORKDAY CASE (LWC)
A Lost Workday Case is any work-related Injury which renders the injured person temporarily unable
to perform any Regular Job or Restricted Work on any day after the day on which the injury was
received. In this case "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.
MEDICAL TREATMENT CASE (MTC)
A Medical Treatment Case is any work-related Injury that involves neither Lost Workdays nor
Restricted Workdays but which requires treatment by, or under the specific order of, a physician or
could be considered as being in the province of a physician.
Medical Treatment does not include First Aid even if this is provided by a physician or registered
professional personnel. Examples of MTCs are to be found in Appendix 4.
NEAR MISS
A Near Miss is an Incident which potentially could have caused Injury or Occupational Illness and/or
damage (loss) to people, assets, the environment or reputation, but which did not.
OCCUPATIONAL ILLNESS
An Occupational Illness is any work-related abnormal condition or disorder, other than an Injury,
which is mainly caused by exposure to environmental factors associated with the employment. It
includes acute and chronic Illness or diseases which may be caused by inhalation, absorption,
ingestion or direct contact.
Whether a case involves a work-related Injury or an Occupational Illness is determined by the nature
of the original event or exposure which caused the case, not by the resulting condition of the
affected employee. An Injury results from a single event. Cases resulting from anything other than a
single event are considered Occupational Illnesses. The basic difference between an Injury and
Illness is the single event concept. If the event resulted from something that happened in one
instant, it is an injury. If it is resulted from prolonged or multiple exposures to a hazardous substance
or environmental factor, it is an Illness.
PERMANENT TOTAL DISABILITY
Permanent Total Disability is any work-related Injury which permanently incapacitates an employee
and results in termination of employment.

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OPU/JV/HCU PREMISES
OPU/JV/HCU premises are:
-

those owned by the OPU/JV/HCU

those rented by the OPU/JV/HCU

Contractors premises which for a time period are fully dedicated to OPU/JV/HCU operations, and

any other site clearly identified with the brand e.g. retail forecourts under OPU/JV/HCU
management control.

RECORDABLE INCIDENT
Recordable Incident is one where both the managements span of control and exposure hours
accumulation are missing. The incident occurs not under the control of the company or its contractor
while undertaking work-related activities. It is also incident of non-work related activities either inside
or outside company premise which cause injury or damage to property but not due to negligence,
error or omission on the part of company or personnel. The incident is not included in companys
statistics. This is further explained in Appendix 3.
REGULAR JOB
A Regular Job is one which has not been established to accommodate an injured employee. It should
be an existing job or task within the OPU/JV/HCU or Contractors organisation which the injured
person is deemed competent to perform.
REPORTABLE INCIDENT
A Reportable Incident is one that has caused injury to personnel/contractor/third party and/or
damage to company property and/or pollution to environment and hence is required to be reported
to the Group. The incident is included in companys statistics. The incident involves the following
criteria:
i)

Work-related activities carried out by company/contractor/third party personnel on company

premise and/or outside company premise, where exposure hours are accumulated, and /or;

ii)

Span of Control. The company has full controlling influence to implement controls at location
and monitor effectiveness, and/or;

iii)

Time of incident. The incident occurs during working hours including lunch hours, overtime
and traveling, and/or;

iv)

Non-work related activities but inside company premise which has caused injury to
personnel/contractor/third party or damage to property due to negligence, error or omission
on the part of company.

This is further explained in Appendix 3.

REPORTABLE WORK INJURY
A Reportable Work Injury is any Work Injury which results in:
i) fatality
ii) permanent total disability
iii) permanent partial disability
iv) lost work days

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v) restricted work days

vi) medical treatment
Any injury which progresses from one category to a category higher on the above list shall be
recorded in the higher category only.
RESTRICTED WORK CASE (RWC)
A Restricted Work Case is any work-related Injury which results in a work assignment after the day
the incident occurred that does not include all the normal duties of the person's Regular Job. The
restricted work assignment must be meaningful and pre-established or a substantial part of a Regular
Job.
ROAD TRAFFIC ACCIDENT
An Incident which has involved a vehicle and which has resulted in Injury, Illness and/or damage
(loss) to people, assets, the environment or the OPU/JV/HCUs reputation.
SECURITY INCIDENT
A Security Incident is one which involves purposeful or deliberate attempts to defraud, cheat or steal
property or possessions of the Reporting Company or to willfully injure an employee of a Reporting
Company or Reportable Contractor.
THIRD PARTIES
Third Parties are persons or organisations which are not employed by or contracted to the Reporting
OPU/JV/HCU or Contractor.
TOTAL REPORTABLE CASES (TRC)
Total Reportable Cases are the sum of Fatalities, Permanent Total Disabilities, Permanent Partial
Disabilities, Lost Workday Cases, Restricted Work Cases and Medical Treatment Cases.
TOTAL REPORTABLE CASE FREQUENCY (TRCF)
The Total Reportable Case Frequency is the number of Total Reportable Cases per million Exposure
Hours.
TOTAL REPORTABLE OCCUPATIONAL ILLNESS (TROI)
Total Reportable Occupational Illnesses are the number of Occupational Illnesses. Any identified
Occupational Illness known to the Company is to be included, even if no lost/restricted workdays are
involved and/or no medical treatment is given. A single exposure can give rise to several
Occupational Illness cases.
TOTAL REPORTABLE OCCUPATIONAL ILLNESS FREQUENCY (TROIF)
The Total Reportable Occupational Illness Frequency is the number of Occupational Illnesses per
million Exposure Hours.
A work-related Fatality is a death resulting from a work-related Injury or Occupational Illness,
regardless of the time intervening between Injury/Illness and death.
WORK INJURY
A Work Injury is an injury or illness, regardless of severity, which arises from a single event (or a
number of events close together in time) in the course of Employment.
In cases where this definition gives reasons for doubt, an injury should be treated as a Work Injury.

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Injuries in the course of Employment which are caused by willful acts are, in general, treated as Work
Injuries.
Injuries caused by the deficiencies in equipment or management controls for which the Reporting
Company is responsible are treated as Work Injuries, even when they occur outside working hours.
Occupational illnesses and death from natural causes are not considered as Work Injuries for the
purpose of this Guide.
WORK RELATED
For the purpose of this document, the term, "Work-Related" is used to describe those activities for
which management controls are, or should have been, in place. Incidents occurring during such
activities are reportable and will be included in the statistics.
In order to encourage consistency in the reporting practices of PETRONAS, as a minimum, the
following activities are considered work-related as they are susceptible to incidents with significant
impact for which management controls should be in place:

all work by OPU/JV/HCU personnel;

all work by Contractor personnel on OPU/JV/HCU premises, and

all work by Contractor personnel on non-OPU/JV/HCU premises for which it is concluded on the
basis of risk considerations that Company and Contractor management controls are required.

For OPU/JV/HCU personnel, "Work" includes attending courses, conferences and OPU/JV/HCU
organised events, business travel, field visits, or any other activity or presence expected by the
employer.
For Contractor personnel, the same activities are included when they are executed under a contract
on behalf of the OPU/JV/HCU. Contractor includes all sub-contracted personnel.
Where it is impossible or inappropriate for the OPU/JV/HCU to seek to impose management control
on Contractor exceptions may be justifiable. Examples may be found in areas where Contractor
services are not dedicated to the company e.g.:

manufacturing of components in a factory together with the manufacture of components for other
customers;

construction at a Contractor's fabrication site shared by other customers;

delivery of goods to company locations by a Contractor who is also employed for delivering goods
to other companies during the same journey, and

customer collection of OPU/JV/HCU products, where the vehicle and drivers are under the control
of the customer.

The OPU/JV/HCU should make a conscious, balanced and documented decision whether or not to
maintain management controls and include incidents in the performance indicators.

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APPENDIX 2: EXAMPLES AND INTERPRETATIONS

1

TRANSPORTATION-RELATED INCIDENTS

All work-related injuries and illnesses are to be reported and included in statistics. Please refer to PTS
60.2401 Land Transportation Safety Guiding Principles, Minimum Standards and Key Performance
Indicators for the requirements of reporting transportation statistics.
1.1

TRANSPORTATION OF PERSONNEL

Considered To Be Work-Related

Personnel travelling in OPU/JV/HCU-owned or arranged transport.

Personnel travelling exclusively on OPU/JV/HCUs business who decided to use public or private
transport instead of OPU/JV/HCU-owned or arranged transport. For example, travelling from their
normal workplace or office to a temporary place of work such as fabrication site; or travelling from
temporary accommodation e.g. base camp or transit place to a place of work.
b)

Not Considered To Be Work-Related

OPU/JV/HCU and Contractor personnel commuting between home and normal work place on
other than OPU/JV/HCU arranged transport.

Non business-related travel in vehicles that are allocated to employees or Contractor

personnel for their unrestricted personal use.

OPU/JV/HCU and Contractor personnel travelling (even at irregular hours) from their home to
a regular assembly point where they are collected in transport specially furnished by their
employer.

Personnel deviating from a business trip for personal reasons provided this does not breach
OPU/JV/HCU procedures.

Example 1: An employee has an OPU/JV/HCU vehicle for which he/she has unrestricted personal
use. The employee is due to attend a business meeting some distance away on a Monday morning.
The employee decides to leave on the Friday and break his journey by visiting friends. An incident
occurs at that time. It is not work-related.
Example 2: Another employee has to use a pool car for a similar business meeting but persuades the
pool supervisor to breach OPU/JV/HCU procedures and release the car on the Friday so he/she can
visit friends. If an incident occurs at that time it is work-related.

Notes:
Where an Incident occurs during travel in non OPU/JV/HCU arranged transport, and subsequent
investigation shows that OPU/JV/HCU transport should have been provided (because, for example
incidents during this activity could create a negative impact on the OPU/JV/HCU) then the incident
should be considered work-related.
Example 3: An employee has to travel from home to the local airport for a weekly shift at an interior
location. If the roads are safe and transport by private vehicle is the norm, then this would be
considered as commuting. However, given the same situation but the road is known to be dangerous
e.g. as a result of many armed robberies, OPU/JV/HCU transport should be provided or arranged. If
no OPU/JV/HCU transport is provided then the Incident involving private transport is considered workrelated.

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Example 4: A ship crew member is travelling ashore by launch for an authorised recreational trip. The
employer is expected to arrange safe transport. Therefore, if an Incident occurs, e.g. from a collision
of the launch with another ship, any injuries would be considered to be work-related
1.2

TRANSPORTATION OF GOODS AND EQUIPMENT

Considered to be work-related

Transportation of goods and equipment within OPU/JV/HCU managed locations.

Transportation of goods and equipment on OPU/JV/HCU owned or contracted transport (e.g.

cars, vans, OPU/JV/HCU aircraft, etc.)

Transportation of goods and equipment readily identifiable as related to the OPU/JV/HCU

operations. (e.g. seismic vehicles, land drilling rigs etc.)

Not considered to be work related

1.3

Those transport activities which are not primarily dedicated to the supply of goods and
equipment for the OPU/JV/HCU or its Contractors and which are not readily identifiable as
related to OPU/JV/HCU or its Contractors and do not present a high risk to the Company (e.g.
delivery of mail, use of road, air and sea freight, Contractors engaged on multi deliveries.)
TRANSPORTATION OF PRODUCT

Considered to be work-related

All incidents which occur to OPU/JV/HCU employees, and to Contractors on OPU/JV/HCU

premises or working under the OPU/JV/HCUs management control.

Example: A road hauler is working under a long term contract to deliver product on the
OPU/JV/HCU's behalf. The hauler operates its own HSE-MS, has ISO 9000 and ISO 14001
accreditation and does not work exclusively for the OPU/JV/HCU. An incident which occurs during the
time the hauler was delivering product for the OPU/JV/HCU would normally be included in the
OPU/JV/HCU statistics as would the exposure hours.

Transportation within OPU/JV/HCU-managed

pipelines.

locations /

by

OPU/JV/HCU-managed

Transportation in PETRONAS branded road cars.

Not considered to be work related

2.

Any incidents to Contractors not working under the OPU/JV/HCUs management control.
ENVIRONMENTAL INCIDENTS

The purpose of this section is to illustrate with examples types of Environmental Incidents, and in
particular to clarify what is an environmental incident.
2.1

OIL AND CHEMICAL SPILLS

When a spill is not contained within the fence or system, it should be considered as an environmental
incident.
a)

Fuel oil spill during work on pipeline

A large diameter fuel oil pipeline in the off plot area of a refinery was being opened up for
maintenance. Because the line had not been adequately cleared beforehand, around 1 tonne of fuel
oil spilled into the pipe track. The majority ran off into the site drains but was collected in the
interceptor system and recovered. None of the oil passed through the interceptor outfall to the stream.

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Although the spill was contained within the fence, it should be investigated to prevent recurrence.
If the same spill had occurred under conditions of high rainfall and some of the oil had been
discharged through the outfall and recovered from the stream, the spill should then be counted as an
environmental incident.
b)

Diesel oil spill from ship

A vessel was berthed in port. Diesel oil was being transferred internally from the wing tanks to fuel
settling tanks. The settling tank overflowed spilling diesel onto the deck of the vessel and
subsequently approximately 100 litres went into the harbour. The vessels Shipboard Oil Pollution
Emergency Plan was put into operation and the oil was dispersed within an hour. The Authorities
were notified. The master of the vessel was subsequently charged under section 12-2 of MARPOL for
illegally discharging oil.
This was clearly an environmental incident. The fact that the Authorities were involved, and the
incident attracted local media attention, means that it should also be considered as a reputation
incident. To avoid duplication the incident should be classified and reported on basis of the highest
rating.
c)

Waste paint tins

Three 5 litre tins of liquid paint all partly full were found in a general waste skip which had been
returned from an offshore installation to a landfill site. The waste was detected by the landfill operator
and constituted a "waste non-compliance". If it had gone into the landfill this would have breached
statutory criteria and could have led to prosecution.
Although it was spotted before it went in to the landfill this incident should be considered as a minor
breach of statutory criteria, and therefore an environmental incident. As there had been previous noncompliances on that landfill location which had come to the attention of the local press, the impact on
reputation should also be considered.
ATMOSPHERIC EMISSIONS
Fugitive emission of hydrogen sulphide.
A refinery sour water pump seal failed and released hydrogen sulphide into the plant area, triggering
the toxic gas detection/alarm system. The pump was quickly shutdown and isolated. There were no
external complaints and it was estimated that the hydrogen sulphide in air concentration at the fence
was below the odour threshold.
2.3

COMPLAINTS

a)

Noise complaint from local resident

A resident of the community close to a refinery complained of a high noise intermittently overnight.
The complaint was investigated and the source of noise tracked down to a compressor local alarm
siren, which was faulty. Even though there were no prescribed maximum noise limits in the local
community, the Complaint should be considered as an Environmental Incident.
b)

Smoke flare

A call received from the Pollution Inspector that a member of the public had complained that a ground
flare at a natural gas plant was exceptionally smoky over a weekend. The public living near the Plant
have always taken an interest in HSE issues at the Plant, and the incident was discussed at the local
community council meeting. If on investigation this proved to be a Justified Complaint it should be
included as an environmental incident. Because of the local interest it would certainly count as a
Reputation incident. To avoid duplication the incident should be classified and reported on basis of the
highest rating.

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OCCUPATIONAL ILLNESSES

3.1

DETERMINING WHETHER AN ILLNESS IS OCCUPATIONAL

The Occupational Health Management Guidelines define Occupational Illness as "any work-related
abnormal condition or disorder, other than one resulting from an injury, caused by or mainly caused
by exposures at work". In order to determine whether an employee's illness is occupational in nature,
the following questions should be addressed:

Has an illness clearly been identified?

Does it appear that the illness is caused, or mainly caused by, suspected agents or other
conditions at work?

Are these suspected agents present (or have they been present) in the work environment?

Was the ill employee exposed to these agents in the work environment?

Was the exposure to a sufficient degree and/or duration to result in the illness condition?

Was the illness attributable mainly to a non-occupational exposure?

OPU/JV/HCUs should check the "Material Safety Data Sheets" for those substances suspected of
causing employee illnesses in order to verify the relationship between the exposure and the
resulting symptoms.
3.2

RECURRENCE OF SYMPTOMS

Companies are required to report each new Occupational Illness. The recurrence of symptoms from
previous cases should not be reported. Deciding whether the emergence of illness symptoms
constitutes a new event or the recurrence of a previous illness may be complex. Generally, each
Occupational Illness should be reported with a separate entry. However, certain illnesses, such as
silicosis, may have prolonged effects which recur over time. The recurrence of these symptoms
should not be reported as a new case, unless the Occupational Illness results in death, permanent
partial or permanent total disability.
Some Occupational Illnesses, such as certain skin or respiratory conditions, may recur as the result of
new exposures to sensitising or other hazardous agents, and should be reported as new cases.
3.3

PRE-EXISTING CONDITIONS

An employee's physical or mental defect or pre-existing physical or mental condition does not affect
the reportability of a subsequently contracted Occupational Illness. If in such circumstances an illness
is caused or mainly caused by exposures at work, the OPU/JV/HCU must report it without regard to
the employee's pre-existing physical or mental condition.
3.4

MEDICAL VERIFICATION BY A MEDICALLY QUALIFIED PERSON

Medical verification is encouraged but not required for reportability. However, companies have the
ultimate responsibility for reporting in good-faith. In case of doubt a medical opinion should be sought.
If a company doubts the validity of an employee's alleged illness and there is no substantive or
medical evidence supporting the allegation, the company need not report the case.
The following examples are intended to clarify the boundaries between Occupational and non
Occupational Illness, and also between Occupational Illness and Work-Related Injury.

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3.5

EXAMPLES OF OCCUPATIONAL HEALTH ILLNESSES

a)

BACK PROBLEMS

A back problem shall be considered work-related if:

i)

there is a clear record of an Incident such as a slip, trip, fall, sudden effort or blow on the
back, or

ii)

the employee was engaged in a work activity which produced a physical condition resulting
from a single identifiable over-exertion.

A back problem shall be considered an Occupational Illness if it is caused by continued exposure to

over-exertion.
Example 1: A worker was installing a window-mounted air-conditioning unit. As the worker was sliding
it into place, it tilted and started to fall. As the worker caught it and forced it into place, the worker felt
a sharp pain in the back. This would be considered work-related Injury.
Example 2: A woodcutter's foot slipped in the process of swinging an axe and a back pain developed
immediately. This would be considered a work related injury, since the onset of symptoms was
directly associated with a incident (slip) which occurred in the course of and arose out of employment.
Example 3: An employee reported severe back pain which gradually developed towards the end of
each workday, but could not attribute the condition to any specific event or activity. After reviewing the
employee's work assignments, it was concluded that the condition resulted from continuous overexertion in the performance of the employee's duties. The case, therefore, would be considered an
Occupational Illness.
b)

BURNS

Contact with a hot surface or a caustic chemical which produces a burn in a single contact would be
defined as an injury. Sunburn or welding flash burns, on the other hand, which result from prolonged
or repeated exposure, are considered Occupational Illnesses.
c)

CUMULATIVE MUSCLE STRAIN

A cumulative muscle strain is where injury results from short-term over-stressing of a group of
muscles. For example, a clerk who is usually involved in work that is not physically demanding is
asked to assist in unloading a large shipment of heavy items by hand, a task which the clerk is
required to do all day. Although the clerk feels no discomfort that day, the following morning the
clerk's right shoulder and back muscles are so sore that the clerk is unable to perform the normal job
effectively and has to be given specially selected duties. The injury was consistent with the type of
work performed on the previous day and the case would be considered a work-related Injury.
d)

CARPAL TUNNEL SYNDROME

Carpal tunnel syndrome is a condition involving compression of the median nerve in the wrist which
results in tingling, discomfort and numbness in the thumb, index, and long fingers. Because workrelated carpal tunnel syndrome cases almost always result from repetitious movement, they should be
classified as Occupational Illnesses. The classification for these cases should be "disorders
associated with repeated trauma"
e)

DERMATITIS

A chemical worker contracted a mild case of dermatitis on both hands while working with a solution for
several hours. The employee was sent to the doctor, who recommended application of a topical lotion
(a commercial, non-prescription remedy). The employee bought a bottle of the lotion and treated the
rash for a few days until it disappeared. There were no subsequent visits to the doctor. The rash did
not prevent the employee from performing all the duties of the job. If considered an Injury, the case

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would not be reportable since no medical treatment was provided. However, since the case almost
certainly did not involve a single instantaneous exposure, it should be classified as an Occupational
Illness. Consequently, the kind of treatment given by the doctor (none in this case) is immaterial, since
all Occupational Illnesses are reportable.
f)

ANIMAL BITES AND INSECT STINGS

Animal and insect bites and stings (and ensuing consequences ) are normally considered as workrelated Injuries if such bites and stings occur in the course of employment. However, repeated
exposure may result in disorders which are considered Occupational Illnesses.
Example 1: A lineman engaged in routine work was bitten by a snake. The injury would be
considered a reportable Injury.
Example 2: A member of a party clearing jungle for seismic work was bitten by insects carrying the
disease leishmaniasis. The resulting sickness would be considered an Occupational Illness.
Example 3: Malaria or other diseases that result from a single bite, but involve multiple exposures to
mosquito/insect stings, are classified as an Occupational Illness
g)

AGGRAVATION OF AN EXISTING PHYSICAL DEFICIENCY

If aggravation of an existing physical deficiency arises out of an Incident in the course of employment,
any resulting increased disability shall be considered a work-related Injury and classified according to
the ultimate extent of the disability.
Example 1: An employee with a known knee defect wrenched it whilst climbing down a ladder, when
the bottom rung gave way. This aggravation required medical attention and would therefore be
considered a work-related Injury.
Example 2: An employee with a known knee defect suffered a recurrence of the disability while the
employee was walking up steps. The incident arose "solely" out of the employee's pre-existing
deficiency and therefore the resulting disability would not be considered a work-related Injury.
Example 3: An employee with a blister unrelated to work knocked the top off the blister in the course
of the employee's work activity. The broken blister became infected and resulted in lost time. This
would be considered a work-related Injury.
h)

REACTION TO MEDICAL TREATMENT

The reportability of an employee's disorder as a result of medical treatment depends upon whether
the treatment was for work-related purposes.
Example 1: An employee going on a business visit was vaccinated against cholera. Some days later
the employee was taken ill and the illness was linked to the vaccination. This would be considered an
Occupational Illness.
Example 2: An employee is inoculated against influenza as part of a programme provided by the
OPU/JV/HCU. An illness arising from the inoculation would be considered an Occupational Illness.
Example 3: An employee is inoculated by OPU/JV/HCU medical personnel with a specific vaccine
prescribed by an outside medical physician for treatment of a non work-related condition. An illness
arising from defective administration of the injection would be an Occupational Illness but not if the
illness arose from an adverse reaction to the vaccine.

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i)

INFECTED LACERATION

An infection resulting from a laceration should be classified as a work related injury because the
classification is based on the original event, the laceration, not on the subsequent developments.
j)

HEARING

Noise induced hearing loss should be determined solely on the existing criteria contained in PTS
60.1504 Hearing Conservation Program.
k)

SPECTACLES

An employee goes to a doctor who informs her that prescription glasses must be worn as a result of
work-related eye deterioration caused by the nature of her job. If it can be established that the
disorder was caused or mainly caused by exposures at work, this case would be reportable as an
Occupational Illness since it involves the recognition of an abnormal condition or disorder. However,
an OPU/JV/HCU should distinguish work-related eye problems from those due to ageing or hereditary
factors unrelated to the job.
l)

HEART ATTACKS

Work-related heart attacks are not classified as work related Injuries because they normally do not
result from work accidents or single instantaneous incidents in the work environment. When they
occur, they may be classified as an Occupational Illness, provided they satisfy the same requirements
for work relationship as any other type of Occupational Illness. This means that heart attacks are not
necessarily reportable if they occur in the work environment, but rather that they must result or mainly
result from exposures at work.
m)

INDIVIDUAL SUSCEPTIBILITY

Variations in the characteristics of particular employees of their susceptibility to various illnesses

should not affect reportability.
n)

COMMON SUBJECTIVE SYMPTOMS

Complaints of such common subjective symptoms as general malaise, headache, nausea, are not
reportable if they are not caused or mainly caused by exposures at work. However, in evaluating
these cases, one should be aware that many subjective complaints, including feelings of malaise,
headache, nausea, etc., may be symptomatic of a wide range of diseases, a number of which are
occupational in origin. In this regard, one should pay attention to the distribution of such subjective
complaints with respect to time and place, particularly when such complaints are observed to occur
among one or more groups of employees.
Infectious diseases such as Malaria, Chagas disease are only reportable if they have been confirmed
by clinical testing or by a doctor. If an illness is indigenous to the area and National personnel are
diagnosed with these illnesses on a regular basis, they should not be reported. If the illness occurs
among Nationals who normally do not suffer from the illness it should be reported.
o)

PERMANENT OR TEMPORARY TRANSFERS

Permanent or temporary transfers to another job to remove employees from further exposure to
health hazards are preventive in nature, and if no Occupational Illness has occurred, are not
considered reportable events.
p)

WORK-RELATED STRESS

Only report those cases where there is an identifiable organisational and/or interpersonal factor in
relation to work and the working environment which has resulted in a stress related disorder requiring

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significant intervention such as specific counselling or treatment, modification of duties or loss of time
from work.
4

REPORTABLE AND RECORDABLE INCIDENTS

a)

REPORTABLE INCIDENT
i)

Injurious incidents involving contractors personnel at oil platform fabrication yard where
elements of company management controls exist.

ii)

Injurious incident involving company personnel at PERMATA Training Centre. The

statistics belongs to PERMATA due to the area is under PERMATAs control, if there is
negligence in part of PERMATA that causes the incident. If negligence is due to the
personnel, the statistics goes to that OPU/JV/HCU.

iii) Injurious incidents involving company personnel at locations not belong to PETRONAS
such as NIOSH. The statistics should go to OPU/JV/HCU if there is negligence from the
personnel. Otherwise, it is categorised as Recordable Incident.
iv) Fire due to lightning.
v) Damage to companys asset due to act of sabotage.
vi) Visitor fell through uncovered/broken drain grating in the company premise.
vii) Injury while playing football due to major trip hazards or structural failure of goal post in
playing field managed by the company.
viii) Injurious incidents while doing company activities or work including the outsourced
activities or work carried out by contractors and sub-contractors during working hours
including shift hours, lunch hours and overtime at company premise.
ix) A robbery inside a security protected area such as office and depots where
managements control exists.
x) Injurious incident while doing company activity/work including outsourced activity during
the working hours at third party premise or public area where the company has full control
of the event.
xi) Injurious incident while doing company activity/work while using company vehicle or
company arranged vehicle including delivering products to customers either within
company premise or outside company premise.
b)

RECORDABLE INCIDENT
i)

Fatal road tanker accident due to third partys fault .

ii)

Customer killed in a robbery at the gas/service station.

iii) A football player playing inside the company premise sprained his ankle after being
tackled by opponent player.
iv) Injurious incident while doing company activity/work including outsourced activity during
the working hours at third party premise or public area where the company has no control
of the event.
v) Injurious incident to or from work place to home.
vi) Injurious incident outside company premise after working hours.

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vii) Injurious incident while transporting equipment from supplier warehouse/shop to company
premise as the controls of transportation fall under the supplier.
viii) Injurious incidents while travelling using public transportation on company activity/work.
5

OTHER EXAMPLES

a)
ENTERTAINMENT OF OR BY CUSTOMER, SUPPLIER OR OTHER BUSINESS
CONTACTS
An illness caused or mainly caused by exposures which occur while the employee is entertaining a
customer, supplier or other business contact, or while the employee is being entertained by a
customer, supplier or other business contact, for the purpose of transacting, discussing, or promoting
business, would be considered an Occupational Illness.
b)

HORSEPLAY

An injury inflicted by, or arising out of, horseplay during work shall be considered a work-related
Injury. For example, an employee was showing off by operating a fork lift which the employee was not
familiar with nor authorised to use. The employee lost control, struck another employee and was
injured. Although the employee was engaged in a prohibited activity, the employee's injury, as well as
that occurring to the fellow employee, would be considered a work-related Injury.
c)

INJURIES DURING TRAINING

An employee attends a training course at a training school or other site and sustains an Injury. The
training period is to be considered as a normal work period for reporting purposes. If the Injury is
sustained during the duration of the training sessions then it is a work-related Injury. However if the
Injury occurs in the employee's own recreational time, and is not attributable to failure of management
controls of the training centre, then it is not work-related.
The Injury is included in the statistics of the Company employing the injured person as are the
exposure hours, unless if there is negligence of controls by the training centre. In this case, statistics
belongs to the training centre. The responsibility for the investigation and follow up rests with the
training centre. The employing Company should receive a full investigation report.
d)

MEAL PERIOD ILLNESSES

An illness caused or mainly caused by exposures which occur during the employee's specifically
defined meal period or other specifically defined off-duty period would not be considered as caused or
mainly caused by exposures at work unless it concerned exposures to hazards specific to the work
area.
Example 1: Food poisoning which results from a meal furnished by the employer would be
considered an Occupational Illness.
Example 2: If, while eating in the same location as described in Example 1, an employee gets food
poisoning from his own supplied food, the case would not be considered an Occupational Illness.

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APPENDIX 3: INCIDENT CLASSIFICATION GUIDING PRINCIPLES, WORK RELATED AND

EXPOSURE HOURS EXAMPLES
An incident is determined whether it is Reportable or Recordable based on the following Guiding
Principles:
a)
b)
c)
d)

Work related
Involved People, Asset or Environment
Control Influence
Location

The following flowchart explains the incident classifications;

RECORDABLE (OPU REPORTABLE) means that the incident is Recordable at PETRONAS reporting
level but Reportable at OPU and Business Unit reporting levels. Example 13, 14 and 16 below
explain the situations.
The following examples are intended to clarify the definition of Exposure Hours, and to give examples
where injuries are considered to be work related even though exposure hours are not being
accumulated at the time of the incident. Examples of identifying incident as either Reportable or
Recordable are also given.
Example 1:

A OPU/JV/HCU or Contractor employee being on board a fixed or floating platform,

rig, flotel, standby boat, supply vessel, construction or maintenance barge etc., but
not on duty. The person is not engaged in work tasks and the OPU/JV/HCU has no
management control in place other than general housekeeping risks, hence, this offduty time is not counted as Exposure Hours. Nevertheless, an Injury occurring during
off-duty periods would be considered a work-related Injury if it is the result of failure of
OPU/JV/HCU controls.

Example 2:

An employee sustains an Injury in an offshore gymnasium in his off duty time.

Management controls had not been breached. The Injury is not work-related. If
controls had been breached, the Injury would be reportable but the Exposure Hours
would not be accumulated.

Example 3:

An office worker living in a suburban area who travels to work by public transport.
This person's Exposure Hours would be the time spent at the office.

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Example 4:

An office worker living in a suburban area who travels to work in transport arranged by
the OPU/JV/HCU. This person's Exposure Hours would be the time spent at the office.
However, an Injury occurring to the employee in transport arranged by the
OPU/JV/HCU would be considered a work-related Injury.

Example 5:

An employee is travelling on OPU/JV/HCU business but in the employee's own time,

i.e. outside the employee's normal working hours. This person's Exposure Hours
would be calculated on the basis of the normal working week. Nevertheless, an injury
occurring to the employee during such transportation would be considered a work
related injury if the vehicle is supplied by OPU/JV/HCU.

Example 6:

An employee working scheduled overtime. This person's Exposure Hours would

include all overtime periods.

Example 7:

An office employee working unscheduled extra hours. Whilst in theory such working
time should be treated as in Example 6, it is generally impracticable to keep records of
such working time and, hence, this person's Exposure Hours should be calculated on
the basis of the normal working week. However, an Injury occurring to the employee
during such overtime working would be considered a work-related Injury.

Example 8:

An OPU/JV/HCU or contractor employee was engaged in OPU/JV/HCU organized

events (e.g. Family Day, community service etc). If the controls are not totally borne by
OPU/JV/HCU, the injury during such activities should not be considered a work
related.

Example 9:

An employee is on the OPU/JV/HCU premise in his off duty time. Even if this time is
spent on OPU/JV/HCU premise, is not accumulated for the calculation of exposure
hours although incidents during this time shall be included if they are the results of
failure or absence of management controls.

Example 10: The employee deviates from a reasonably direct route of travel (side trip for vacation
or other personal reasons). This is not work related. But he would be again be in the
course of employment when he returned to the normal route of travel and Example 5
should apply if travelling time is outside the employees normal working hours.
Example 11: A truck driver, on his way to deliver product, deviates his route to go home / rest area
for lunch / dinner or stay overnight. On the way to that location, he was hijacked /
robbed. This is recordable and not work-related but the driver is subject to disciplinary
/ security action.
Example 12: PETRONAS OPU-A is delivering products / materials to PETRONAS OPU-B using
road transportation. A road accident occurs inside PETRONAS OPU-B compound.
This incident is work-related and the incident owner is PETRONAS OPU-B.
Example 13: An employee from PETRONAS OPU-A attends a training at PETRONAS OPU-B. An
incident happens at PETRONAS OPU-B involving the employee from PETRONAS
OPU-A. This is work-related. Since PETRONAS OPU-B has the control, the incident is
reportable for PETRONAS OPU-B. It is recordable for PETRONAS OPU-A.
Example 14: PETRONAS OPU-A1 NGV tanker was on its way for product delivery to a designated
location when it was hit from rear by another PETRONAS OPU-A2 tanker which is
hired by PETRONAS OPU-B for diesel delivery to a petrol station. The incident is work
related and reportable for PETRONAS OPU-B. It is also reportable for PETRONAS
OPU-A2 at the OPU level. The incident is recordable for PETRONAS OPU-A1.
Example 15: A PETRONAS OPU-A employee attended a meeting with PETRONAS OPU-B at
PETRONAS OPU-Bs site. PETRONAS OPU-A employee suffered an injury in a road
accident in a vehicle provided by PETRONAS OPU-B and driven by PETRONAS
OPU-B driver. Either the accident occurs inside PETRONAS OPU-Bs site or during on
the way to hotel / accommodation after the meeting / for lunch or dinner, the incident is

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work-related and reportable for PETRONAS OPU-B.

Example 16: PETRONAS OPU-A is the Project Owner. PETRONAS OPU-B is a contractor to
PETRONAS OPU-A. PETRONAS OPU-B hires a sub-contractor XYZ. An incident
occurs to sub-contractor XYZs worker. Regardless of where the incident occurs i.e.
PETRONAS OPU-As site, PETRONAS OPU-Bs site, XYZs site or other approved
site/route, the incident is reportable and belongs to PETRONAS OPU-A. However it is
reportable for PETRONAS OPU-B at the OPU level.
Example 17: PETRONAS OPU-A ventures a project in another country at fabrication site X. Incident
occurs at site X. The project is under PETRONAS OPU-A supervision or under
influence of PETRONAS OPU-A supervision. This incident is reportable for
PETRONAS OPU-A.
Example 18: An employee has an OPU/JV/HCU vehicle for which he/she has unrestricted personal
use. The employee is due to attend a business meeting some distance away on a
Monday morning. The employee decides to leave on the Friday and break his journey
by visiting friends. An incident occurs at that time. This is off-the-job recordable.
QUALIFYING STATEMENTS

All incident cases involving Restricted Work Case or worse shall seek consultation from Group
HSE Division. Group HSE Division shall review the classification assigned by OPU/JV/HCUs.
In case where the Reportable and/or Recordable classifications are not clearly or easily
determined, or even disputable, the final decision falls under Group HSE Division.

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APPENDIX 4: MEDICAL TREATMENT CASES AND FIRST AID CASES

MEDICAL TREATMENT CASE (MTC)
The following examples are generally considered medical treatment

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 sterile 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
included in the statistics 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 reported
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.
FIRST AID CASES (FAC)
The following examples are generally considered first aid treatment, i.e. one-off treatment and
subsequent observation of minor injuries:

Application of antiseptics during the first visit to medical personnel

Treatment of first degree burn(s)
Application of bandage(s) during any visit to medical personnel
Use of elastic bandage(s) during the first visit to medical personnel
Removal of foreign bodies not embedded in eye if only irrigation is required
Removal of foreign bodies from wound; if the procedure is uncomplicated, and is, for example by
tweezers or other simple technique
Use of non-prescription medications and administration of a single dose of prescription
medication on the first visit for a minor injury or discomfort
Soaking therapy on the initial visit to medical personnel or removal of bandages by soaking
Application of hot or cold compress(es) during the first visit to medical personnel
Application of ointments to abrasions to prevent them drying or cracking
Application of heat therapy during the first visit to medical personnel
Use of whirlpool bath therapy during the first visit to medical personnel
Negative X-ray diagnosis
Observation of injury during a visit to medical personnel (less than 12 hours duration).

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APPENDIX 5: CLASSIFICATION OF OCCUPATIONAL ILLNESSES

INFECTIOUS AND PARASITIC DISEASES: malaria, food poisoning, infectious hepatitis, dysentery,
lambliasis, legionnaire's disease.
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.
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.
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.
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; vibration (white finger).
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.
CANCERS AND MALIGNANT BLOOD DISEASES: mesothelioma; bladder cancer; leukaemia and
other malignant diseases of blood and blood forming organs.
DISORDERS DUE TO MENTAL STRESS: tension headache, depression, neurosis, "stress",
functional disorders of the gastrointestinal tract.
NOISE INDUCED HEARING LOSS: definition and criteria for reporting are given in the PTS 60.1504
Hearing Conservation Program.
OTHER ILLNESSES AND DISORDERS: Benign tumours; eye conditions due to dust and toxic
agents; other (non-malignant) diseases of blood and blood-forming organs.

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APPENDIX 6: INCIDENT CLASSIFICATION CRITERIA

The Matrix should be used to initiate Initial Notification and Investigation.
HARM TO PEOPLE
Class

Rating

Minor

Slight injury or health effects (resulting in First Aid Case) - Not affecting
work performance or causing disability.

Minor injury or health effects (resulting in Medical Treatment Case,

Restricted Work Case and Lost Workday Case (Lost Time Injury) equals or
less than 4 days) - Affecting work performance, such as restriction to activities
(Restricted Work Case) or a need to take a few days to fully recover (Lost
Workday Case). Limited health effects which are reversible, e.g. skin irritation
Major injury or health effects (resulting in Permanent Partial Disability, Lost
Workday Case more than 4 days) -Affecting work performance in the longer
term, such as a prolonged absence from work. Irreversible health damage
without loss of life, e.g. noise induced hearing loss, chronic back injuries; or.
Reportable to government or authority of the country.
e.g. In Malaysia, reportable as per :
1) Serious Bodily Injury as per First Schedule of NADOPOD Regulation 2004.
2) Occupational Poisoning and Occupational Diseases as per Third Schedule
of NADOPOD Regulations 2004.
Single Fatality or Permanent Total Disability-From an accident or
Occupational Illness (poisoning, cancer); or.
Reportable to government or authority of the country.
Multiple fatalities -From an accident or Occupational Illness (poisoning,
cancer); or.
Reportable to government or authority of the country

Major

Description

ASSET DAMAGE
Class
Minor

Rating
1
2

Major
3

Description (replacement cost)

Slight Damage
- No disruption to operation, or
- Asset value less than USD25,000
Minor Damage
- Brief disruption to operation not more than 2 hours, or
- Asset value from USD25,000 to USD100,000
Local Damage
- Shutdown of a single unit, or
- Disruption to operation of plant not more than 1 day, or
- Asset value from USD100,101 to USD1,000,000, or
- Reportable to government or authority of the country
E.g. in Malaysia, reportable as per Second Schedule of NADOPOD
Regulations 2004.
Major Damage
- Shutdown of multiple units, or
- Disruption to operation of plant more than 1 day (e.g. fire incident), or
- Asset value from USD1,000,001 to USD10,000,000, or
- Reportable to government or authority of the country
- Plant recovery within 1 6 months
Extensive Damage
- Total facility shutdown, or
- Asset value in excess of USD10,000,000, or
- Reportable to government or authority of the country
- Plant Recovery more than 6 months

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ENVIRONMENTAL EFFECT
Class

Rating

Description

Minor

Slight Effect
Leak/Spill contained within the secondary containment and
does not reach water and soil, and minimal volatilization to atmosphere
causing negligible impact to local environment

Minor Effect
Spill/leak contained within secondary containment causing
volatilization to atmosphere
limited contamination of soil or water within the containment area
non-permanent impacts to the environment
Emission/discharge exceeding company limit (where available) but within
legislative limit

No immediate cumulative and/or delayed effect

Major

Local Effect
Spill/leak spreading outside the secondary containment but remain within
facility perimeter (for onshore operation) ** , causing limited soil/water
contamination OR resulting in Potential Consequence A, B or C below
Emission/discharges exceeding legislative limit OR resulting in Potential
Consequence A below
Potential Consequence
A) Cumulative and/or delayed environmental impact
B) Recovery < 1 month
C) Rehabilitation < 6 months
** For offshore operation, spill/leak into marine environment but limited potential
of contamination to the marine water

Major Effect
Spill/leak spreading outside the facility perimeter, managed to be recovered
but causing major contamination OR resulting in Potential Consequence
A, B or C below
Emission/discharges exceeding legislative limit with possible prosecution OR
resulting in Potential Consequence A below
Potential Consequence
A) Immediate impact with serious environmental damage
B) Recovery 1- 3 month
C) Rehabilitation 6 12 months

Massive Effect
Spill/leak spreading outside the facility perimeter, causing
massive
contamination OR resulting in Potential Consequence A, B or C below
Emission/discharges resulting in legal prosecution with possible total shutdown
of facility, OR resulting in Potential Consequence A below
Potential Consequence
A) Immediate impact with severe environmental damage
B) Recovery > 3 months
C) Rehabilitation > 12 months

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IMPACT ON REPUTATION
Class
Minor

Rating
1
2

Major

Description
Slight impact - Public awareness may exist, but there is no public concern.
Limited impact - Some local public concern. Some local media and/or local
political attention with potentially adverse aspects for company operations.
Considerable impact - Regional public concern. Extensive adverse
attention in local media. Slight national media and / or local / regional political
attention. Adverse stance of local government and/or action groups.

National impact - National public concern. Extensive adverse attention in

the national media. Regional / national policies with potentially restrictive
measures and/or impact on grant of licences. Mobilisation of action groups.

International impact - International public attention. Extensive adverse

attention in international media. National / international policies with
potentially severe impact on access to new areas, grants of licences and/or
tax legislation.

SECURITY BREACH
Class
Minor

Rating
1
2

Major

Description
Slight impact
- Trespassing
- Theft/Buglary
Minor impact
- Minor criminal case inside companys premise
- Community disturbances
- Civil strife not affecting operation
- Armed robbery
- Criminal incident which causes public concern
Major impact
- Major criminal case resulting in injury
- Political/Civil strife affecting operation
- Arson
Serious impact
- Major criminal case resulting in single fatality
- OPU Internal or Labour Unrest
- Kidnapping
- Hostage situation or death threat inside companys premise
Extensive impact
- Major criminal case resulting in multiple fatalities
- Acts of terrorism involving the companys asset or operations
- Bomb threat, Sabotage

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APPENDIX 7: INCIDENT INITIAL NOTIFICATION

The Incident Initial Notification follows the following time requirements.
Class
Minor

Rating
1
2

Timing
Within 24 hours

Reporting to Who
- OPU Internal Management
- Authority (if required)
-COMCEN

Major

Within 24 hours
- Head GHSED
- Respective VP & EVP
- Country Manager for
International Operation
In addition to:
- OPU Internal Management
- Authority

Within 1 hour
- COMCEN
- Presidents Office

5
Within 1 hour

- Respective VP & EVP

- Country Manager for
International Operation
- Head GHSED
- VP Legal
- SGM Corporate Services /
Corporate Affairs
In addition to:
- OPU Internal Management
- Authority

Activation of Tier 2 and Tier 3 Emergency Response should be notified within 1 hour as per PTS
60.0112 Group Contingency Planning Standard.
The attached Initial Incident Notification form which is a minor update to a similar form found in PTS
60.0112 Group Contingency Planning Standard, should supersede any previous Initial Incident
Notification form.

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OPU:
Tel:
INCIDENT NOTIFICATION FORM
Fax:
President (President Office) Business Head (EVP) Others:__________
COMCEN To Notify:
Respective VP
Tel:+603-2331 2141/42/43 GHSED
Legal
CSD
Fax:+603-2161 1696
Corporate Affairs
Country Manager
GRMU
IBU
Incident Location:
Incident Date:
Onshore:
Incident Time:
Offshore:
Department Responsible:
Process Incident

Date Prepared:

Time Prepared:

Non Process Incident

NATURE OF INCIDENT / TYPE OF INCIDENT:

Fire / Explosion Injurious Incident Environment
Others:
Loss of Containment / Gas Leak / Spill Spillage Vol: _____Recovered Vol:________
Security:
Industrial Unrest Kidnapping / Hostage Bomb / Death Threat
Community Disturbance Others: _______________________
Transportation:
Land Air Water
Please specify: _________________
Emergency Response Level:
No Tier 1 Tier 2 Tier 3
HSE:

Direct Cause:
Activity Involved:

Sub-Direct Cause:

INCIDENT POTENTIAL
Incident terminated at __________ hrs.
Incident Under Control.
Incident currently not under control, but can be handled with available resources.
Incident will require additional resources (e.g., authorities, contractors, mutual aid).
Incident will likely generate significant public affairs/community, authorities relations issues.
ACTUAL IMPACTS
Life
Public

Environment
Land

Property
Water

Operations
Business and Reputation
Exact Location: _________________________

CASUALTY / FATALITY
Fatality No. : _____ Injury No. _____

rd

Who? PETRONAS / Contractor / 3 Party : ___________

AUTHORITIES INFORMED OR EQUIVALENT (International Operation)

Police Fire Dept. Medical DOSH DOE Others :_________ Date Informed :
BRIEF DESCRIPTION OF INCIDENT (Who, What, & Consequence)

MITIGATION ACTION TAKEN:

ADDITIONAL COMMENT / INFORMATION:

Prepared/Reported by:

Designation:

Approved and Submitted by:

Designation:

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APPENDIX 8: INCIDENT DIRECT CAUSE CLASSIFICATIONS

The Incident Direct Cause Classifications are divided into Main Category and Sub-Category as
follows:
Main Category
1
TRANSPORTATION

EXPOSURE/CONTACT

STRUCK

CAUGHT

ENERGY

FALL

INTEGRITY FAILURE

ERGONOMIC

ASPHYXIATION

10
11

ILLNESS
LOSS OF CONTAINMENT

12

BIOLOGICAL

13

CRIME

14

NATURE

Sub Category (Not Exhaustive)

1 Land Accident
2 Aviation Accident
3 Marine Accident
1 Exposure to Substance / Sources of Energy
2 Exposure (Contact) by Substance / Source of Energy
3 Exposure (Contact) with Substance / Source of Energy
1 Struck / Hit By
2 Struck / Hit Against
3 Punch Through / Nip
1 Caught On
2 Caught Between
3 Caught In
1 Electrical
2 Fire
3 Explosion
4 Lightning
5 Water
1 Fall from Height / Fall to Below
2 Fall to Surface / Slip and Fall / Trip and Fall
1 Equipment Failure
2 Structural Failure
1 Exertion
2 Bodily Reaction
1 Oxygen Deprivation
2 Drowning
3 Confined Space
Sudden Collapse
1 Overflow
2 Spill
3 Leak
1 Poisoning
2 Animal Attack / Insect Bite
3 Infection
4 Disease
1 Trespassing
2 Theft
3 Buglary
4 Threat
5 Sabotage
6 Hijack

1
2
3
4
5

Flood
Earthquake
Tsunami
Landslide
Strong Wind / Tornado / Hurricane

The definitions and examples of some of the terms in the Sub-Category:

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EXPOSURE
Over a period of time, someone is exposed to harmful conditions.
Example:
A person is exposed to levels of noise in excess of 90 dBA for 8 hours.
Other examples are inhalation of fume, and exposure to radioactive.
CONTACT BY
Contact by a substance or material that by its very nature is harmful and causes injury.
Example:
A person is exposed by steam escaping from a pipe.
CONTACT-WITH
A person comes in contact with a harmful material. The person initiates the contact.
Example:
A person touches the hot surface of a boiler.
Other examples: Skin contact with chemical. Contact with hot/cold surface. Liquid (chemical, hot
water, condensate, steam) Splash.
STRUCK-BY
A person is forcefully struck by an object. The force of contact is provided by the object.
Example:
A pedestrian is struck by a moving vehicle.
Other examples: Hit by falling object, Cut by Object.
STRUCK-AGAINST
A person forcefully strikes an object. The person provides the force.
Example:
A person strikes a leg on a protruding beam.
Other examples: Person hits object. Walking into object.
CAUGHT-ON
A person or part of his/her clothing or equipment is caught on an object that is either moving or
stationary. This may cause the person to lose his/her balance and fall, be pulled into a machine, or
suffer some other harm.
Example:
A person snags a sleeve on the end of a hand rail.
CAUGHT-BETWEEN
A person is crushed, pinched or otherwise caught between either a moving object and stationary
object or between two moving objects.
Example:
A persons finger is caught between a door and its casing.
CAUGHT-IN
A person or part of him/her is trapped, struck, or otherwise caught in an opening or closure. Example:
A persons foot is caught in a hole in the floor.

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FALL-TO-BELOW
A person slips or trips and falls to a surface level below the one he/she is standing or walking on.
Example:
A person trips on a stairway and falls to the floor below.
FALL-TO-SURFACE
A person slips or trips and falls to the surface he/she is standing or walking on.
Example:
A person trips on debris in the walkway and falls.
EXERTION
Someone over-exerts or strains him or herself while doing a job.
Example:
A person lifts a heavy object; repeatedly flexes the wrist to move materials, and: a person twists the
torso to place materials on a table. Interaction with objects, materials, etc. is involved.
BODILY REACTION
Caused solely from stress imposed by free movement of the body or assumption of a strained or
unnatural body position. A leading source of injury.
Example:
A person bends or twists to reach a valve and strains back.

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APPENDIX 9: MONTHLY REPORTING

MONTHLY INCIDENTS REPORT AT PETRONAS OPU/JV/HCU
OPU/JV/HCU : _____________________________________
MONTH
: _____________________________________
4

1.

Brief Description

Third Party

Contractor

Recordable)

PETRONAS

Direct
Cause

(Reportable/

Activity
Involved

Category

Classifi-cation
Rating

Consequence

Location

No

Date & Time

Details of Incident

What Happened (max 40

words)?:

Who Involved (max 20

words)?:

Results/Consequences (max
20 words)?:

Select the relevant wordings:

1

See Appendix 1 and Appendix 3 of PTS 60.0501

Chemical Handling, Welding/Cutting, Electrical Work, Hydrojet Cleaning, Lifting,
Loading/Unloading Activities, Scaffolding, Assemble/Dissemble, Working at Height, Confined
Space Entry, Diving, Excavation, Radiography, Manual Handling, Hydrotesting, Transportation
(Land, Sea, Air), Sports/Recreational Activity Routine Operational Activities (Sampling, Taking
Reading, Flushing), Routine Maintenance Activities (Line Breaking, Calibration, Inspection),
StartUp / Shutdown Activities (Commisioning / Decommisioning), Other (to specify)

See Appendix 9 of PTS 60.0501. Fill in the items in Sub-Category. If none, please put Other
(to specify)

Fatality(x), PTD(x), PPD(x), LWC(x), RWC(x), MTC(x), FAC(x), Property Damage, Pollution,
Operational Interruption, Other (to specify)
PTD = Permanent Total Disability, PPD = Permanent Partial Disability, LWC = Lost Workday
Case, RWC = Restricted Workday Case,
MTC = Medical Treatment Case, FAC = First Aid Case,
(x) = number of people affected

See Incident Classification Criteria in Appendix 6 of PTS 60.0501.

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APPENDIX 10: HSE ALERT FORM

HSE ALERT Ref No:

Title of incident:

Incident

Recommendations
While waiting for detailed investigation report, the following recommended actions or precautions
are to be observed when:
i)

ii)

iii)

iv)

NO WORK IS SO URGENT THAT WE CANNOT TAKE THE TIME TO DO IT SAFELY

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PTS 60.0501

APPENDIX 11: THE INVESTIGATION PROCESS

1

DETERMINATION OF LEVEL OF INVESTIGATION

1.1

General
The notification of an incident triggers the start of the investigation process, which comprises
the consecutive stages as indicated in Figure 1.

1.2

Incident Classification
An incident may result in serious injuries, illness, damage, environmental impact or
alternatively have only minor consequences. Lessons to avoid re-occurrence can be gained
from all incidents. For incidents with minor consequences the potential severity can still be
very high. Investigation of those cases may reveal as much about the deficiencies in HSE
management as cases in which major injury resulted. In isolation, incidents with minor
consequences and minor potential severity may provide little learning, but the collection and
analysis of data from many such incidents show trends which may be used to identify
measures for improvement in the overall HSE performance.
When assessing the potential severity of an incident two parameters are combined:
1. potential injury/damage/environmental impact
2. level of exposure/frequency of occurrence. The investigation effort in terms of team
composition and depth of investigation should be based on actual and potential severity.
The Incident Classification Criteria Matrix (Appendix 6) which is actual consequence should
be used to classify all the incidents prior to the investigation. The matrix should be used to
define the initial classification of incidents and when the initial notification can be reported. It
should also be used to determine the types of investigation to be conducted.

APPOINTMENT OF INVESTIGATORS

2.1

General
The size and composition of an investigation team will depend on one or all of the following
factors:

extent of injury or damage

potential for injury or damage

potential for repetition

departments involved

requirements for specialist knowledge

legal requirements

For many incidents the investigative skill and effort required may be within the capability of
one person, who, for minor incidents, could be the line supervisor.
For the minor incidents, collection and analysis of repetitive cases provide measures of
improvement.
Investigation must be done by trained team members, or at least trained team leader, by
using proven tools, methodology and procedures. Independencies of investigation should be
observed. This can be done by having the Investigation Team led by the unaffected

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department. Multi-expertise team members are recommended, for example for OH cases, OH
Doctor may become one of the investigation team members.
Following the concept of line responsibility for safety, the line should take the lead in incident
investigation.
When the Terms of Reference is established, the Investigation Team should adhere to the
document.
Investigation Kit such as torch light, measuring tape, camera, rope etc should be available.
2.2

Line Responsibility for Investigation

Following the concept of line responsibility, the line function should take the lead in incident
investigation. For all incidents, OPU to initiate internal investigation. A rapid response
from the appropriate level of line management demonstrates management commitment.
First-line supervisors bring their technical skills and familiarity to the task, the process and the
operation, together with their knowledge of the individuals involved. In some investigations
however, the immediate supervisor may have more value as a witness than as a member of
the investigating team. Senior line supervisors and line managers provide their experience
and view events from a perspective based on an overview of a broad area of activity. They
are in a better position to detect weaknesses in management systems and can assist in
expediting the investigation process.
HSE personnel can also make a valuable contribution to an investigation. Beside their
contribution of HSE know-how, they can provide comparison with similar situations in other
departments and companies. In addition their independent viewpoint can be useful when
examining established work practices. It may also be valuable to include other technical
specialists and HSE representatives in the team.

2.3

Contractor Incidents
The responsibility for investigating contractor incidents lies with the relevant Contractor. It is
recommended that:

Contractor's arrangements for carrying out incident investigation should be

established at the pre- qualification stage

Company should monitor such investigations and follow-up

findings and recommendations from the investigation should be discussed between

the managements of the Company and Contractors

an investigation should be conducted by the Company, either separately from or

jointly with the Contractor, when a Contractor incident occurs on Company premises
or involves Company property or interests.

Irrespective of the contractual obligations of the Contractor, the contract holder remains
responsible for ensuring that reportable incidents are treated in accordance with the
PETRONAS Group Guidelines with respect to timing and completeness of reporting.
2.4

Investigation by External Investigation Team

Incident investigation shall be conducted by independent party to ensure the effectiveness of
the investigation.
For rating 3 incidents, OPU shall lead the investigation with participation of external team
members to provide independent view on the incident. The team leader shall be from the
senior management and the team members shall comprise of personnel external from the
department or project involved in the incident.

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For rating 4-5 incidents, Business Head in consultation with GHSED shall appoint external
Investigation Team. The external team members shall be from other OPUs.
An OH Doctor should be involved in the investigation that is related to occupational illness.
OPU/JV/HCU should notify the Head and/or General Manager of Group HSE Division when
investigation is to be initiated via e-mail or other practical means. Group HSE Division should
respond within 24 hours to the request.
2.5

Investigation by Local or National Authorities

In the event that the local authority wishes to investigate, the Company should nominate a
focal point to liaise with the authorities and to assist them in assembling the information they
require.
Notwithstanding the involvement of the authorities and other bodies, the Company should
carry out its own investigation.
It is likely that the (local) authority investigating the incident may require a copy of the
companys investigation report. However, as it may serve as a basis for, or even as evidence
in, civil or criminal proceedings possibly brought against the Company, its directors or
employees, consultation with the Companys legal advisor is essential before handing over
any such document.

THE INVESTIGATION

3.1

Scope and Aims

The scope of the investigation should be such as to achieve the following primary aims:

to identify the root causes of the incident such that actions can be taken to prevent
recurrence of future incidents

to review the application of management practices and their impact on HSE

to establish the facts surrounding the incident for use in relation to potential insurance
claims or litigation

to meet relevant statutory and PETRONAS Group requirements on incident reporting.

This may necessitate review of aspects remote from the location and time of the Incident.
3.2

Timing
An investigation should be carried out as soon as possible after an incident, preferably within
24 hours as the quality of evidence can deteriorate rapidly with time, and delayed
investigations only add to the uncertainties surrounding the investigation.

3.3

Background Information
Appropriate background information should be obtained before visiting the incident location.
Such information could include:

procedures for the type of operation involved

records of instructions/briefings given on the particular job being investigated
location plans
command structure and persons involved
contractual requirements
aspects of the HSE Case as in Activity Specification Sheet and Hazard Register HSE

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MS requirements as appropriate
messages, directions etc., given from base/head office concerning the work.

Before proceeding out to the scene of the accident, the team leader will brief the team the
information available thus far relating to the incident in terms of the harm done and actions
taken. The team will draw up the preliminary Hazard Event Target (HET) diagram as a
guide for gathering information. Where the barriers and controls can be identified they should
be reflected to produce the preliminary core diagram in the investigation process
3.4

The Investigation Method

The method of conducting an investigation consists of the following activities:

fact finding / information gathering

inspecting the location
gathering or recording physical evidence
interviewing witnesses
reviewing documents, procedures and records
conducting specialist studies (as required)
resolving conflicts in evidence
identifying missing information
recording additional factors and possible underlying causes including human factors.

During the initial stages of every investigation, investigators should aim to gather and record
all the information which may be of interest in determining causes.
Investigators should keep an open mind and considering the full range of possibilities.
Checklists can be very useful in the early stages to keep the full range of enquiry in mind, but
they cannot cover all possible aspects of an investigation, neither can they follow all individual
leads back to basic causal factors. When checklists are used, their limitations should be
clearly understood. Make use of the core diagram to act as prompters on areas to look at,
effectiveness of which could have prevented the accident.
3.4.1

Fact Finding information gathering

The objective of this stage of the investigation is to collect as much information as possible.
Figure 1 provides an overview of the investigation and analysis process.
The scope of an investigation can be divided into five areas:

people
environment
equipment
procedures
organisation

Conditions, actions or omissions for each of these may be identified, which could be factors
contributing to the incident or to subsequent injury, damage or loss.
A factor to consider during an investigation is recent change. In many cases it has been found
that some change occurred prior to an incident which, combining with other causal factors
already present, served to initiate the incident. Changes in personnel, organisation,
procedures, processes and equipment should be investigated, particularly the hand-over of
control and instructions, and the communication of information about the change to those who
needed to know.
The effect of work cycles and work related stress could have an impact on individuals'
performance prior to an incident.
The impact of social and domestic pressures related to individuals' behaviour should not be

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overlooked.
The initial stages of an investigation normally focus on conditions and activities close to the
incident and only immediate causes are usually identified at this stage. However, the
conditions underlying these causes may also need investigating.
Information should be verified wherever possible. Statements made by different witnesses
may conflict and supporting evidence may be needed.
To ensure that all the facts are uncovered, the broad questions of "who?, what?, when?,
where?, why? and how?" should be asked.
After fact finding / information gathering it should be possible to:

give a precise description of the incident, its background, timing, and the events
leading to it
describe the weather conditions
describe the operations
identify the equipment in use, its capabilities and any failures
describe the locations of key personnel and their actions immediately before, during
and immediately after the incident
describe all pertinent instructions
identify energy flows that were not controlled
identify operational deviations, other defects or inappropriate use of resources and
equipment
identify changes of staff, procedures, equipment or processes that could have
contributed to the accident
identify shortfalls in relevant personnel skill levels
identify whether alcohol or drugs were contributory
identify what barriers in place did not work or should be in place but missing
identify the effectiveness of safety programmes
comment on response to an accident (first aid, rescue, shut-down, fire-fighting, etc.)
identify damage control and medical treatment actions taken to prevent worsening of
the situation and the condition of injured parties, particularly if disabling injuries or
death ensued
make an inventory of all the consequences of the incident (injury, damage and loss).

What constitute as a fact? A fact is defined as:

-

3.4.2

written document as in work instruction, contract document, permit to work etc.,

physical evidence that can be felt, touched or seen
photographs un-tampered whether paper or digital
a statement that is supported by another. Where there is a difference, it is the role of
the investigation to reconcile the information one way or the other. There is no right or
wrong in an investigation!!
Inspecting the Location

Important evidence can be gained from observations made at the scene of the incident,
particularly if equipment remains as it was at the time of the incident. Similarly, witnesses'
statements can usually be better understood and verified if discussed at site. Witnesses
should be readily available to the investigation team. It is not possible to set rules on
"immobilising" equipment at a location, but as far as possible the site should be kept "as is"
until at least a preliminary investigation has taken place. However, rescue operations or the
presence of residual hazards and/or congestion may justify moving some of the equipment.
Local legislation may prescribe that for certain classes of incident, e.g. fatality or motor
vehicle accident, nothing may be moved without prior permission from the relevant
authorities.

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Photographs paper or digital and/or video film will assist the investigation. However, local
authorities may restrict site access or impound equipment and in such circumstances it may
not always be possible to obtain photographic records. In these situations sketches should be
made.

The investigators should be looking for any conditions in the immediate environment which
could have contributed to the incident. Items to check include:

3.4.3

position of all equipment in relation to other equipment/facilities

the position of valves, spades, set points, recorders, override switches, etc.
the condition of the load-bearing surface
accessibility/evidence of congestion
illumination/visibility and audibility at the location/site
state of house-keeping
the condition of all equipment/facilities
effects of weather
presence of witnesses
evidence of spills or release
odours, discolouration
presence of unauthorised people
evidence of excessive forces
presence/absence of warning signs/notices
results of statutory and other inspections.

Preserving Physical Evidence

In many incidents components or equipment may be damaged, or have failed. In these cases,
it is best to lodge this equipment in a secure place pending more detailed analysis.
3.4.4

Conducting Interviews

People should be interviewed singly and be asked to go step-by-step through the events
surrounding the incident, describing both their own actions and the actions of others. An
interview is best conducted in an environment / surrounding comfortable to the witness. This
is often the place of work or area where breaks are taken.
The value of a witness's statement can be greatly influenced by the style of the interviewer,
whose main task is to listen to the witness's story and not to influence him/her by making
comments or asking leading questions. This requires patience and understanding. If the
investigation is a team effort, great care should be taken not to make a witness feel
intimidated by too many interviewers. Experience has shown that interviews can be effectively
conducted by a pair of interviewers with one listening and asking questions while the other
listens and takes notes, interjecting on new information offerred and if appropriate, the
witness could be accompanied by an independent "friend".
It should be remembered that an investigation team is often seen in a prosecuting role, and
there may be a reluctance to talk freely if people think they may incriminate themselves or
their colleagues. An investigator is not in a position to give immunity in return for evidence,
but must try to convince interviewees of the purpose of the investigation which is to
understand what went wrong and why, not who is to be blamed and the need for frankness.
At the end of an interview the discussion should be summarised to make sure that no
misunderstandings exist. A written record should be made of the interview and this should be
discussed with the witness to clarify any anomalies. Any anomaly in the statement or conflicts
with other evidence must be clarified.

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3.4.5

Records and Procedures

Documentation such as "as-built" drawings, inspection records, instrument and tachograph

records, print-outs, log sheets/books, maintenance records, work permits and load/time
sheets may provide information relevant to the investigation.
Written instructions and procedures provide evidence of pre-planning and individual
responsibilities. The investigation should try to establish the extent to which these procedures
and instructions were understood and acted upon, as these can indicate the effectiveness of
training and supervision. The relevance and extent of application of procedures should be
assessed during the investigation.
3.4.6

Conducting Special Studies

Incidents of an involved or complex nature often require the analysis of specialists to

determine causes of failure. Aircraft crashes, crane failures and explosions are examples of
such incidents, where specialist advice may be required. This should be rapidly identified and
the specialists be involved early in the site assessment.
3.4.7

Conflicting Evidence

It is not unusual for different witnesses to give different accounts of an incident. Human
memory can be unreliable and, even if not motivated by self-protection or other subjective
argument, one person's recollection of an incident can differ from another's in quite important
details. Investigators should note any significant differences in accounts of an event. Faced
with conflicting witnesses' statements, investigators should look for the similarities between
the statements and commonality with other evidence. The objective is to use the evidence to
understand the incident and not to prove the accuracy of individual statements, nor to
apportion blame.
3.4.8

Identifying Missing Information

As the investigation progresses, the investigator(s) should begin to identify the sequence of
events the core diagram and concentrate efforts on Identifying the failed barriers / controls
and the causal chain of events leading to the latent conditions that initiate it.
3.4.9

Underlying Causes and Human Factors

As the extent of physical factors involved in an incident becomes 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.
4

ESTABLISHING THE SEQUENCE OF EVENTS

In the fact finding / information gathering stage of an incident investigation, it is crucial to
obtain all information and (confirmed) facts essential to the understanding of the incident. This
implies back tracking from the initial information found, to discover the reasons behind them.
Gaps that are left in the event sequence should be reviewed to identify alternative scenarios
to complete the sequence. In doing this it may be helpful to consider the human factors
sequence.
(In order to give flexibility for OPU/JV/HCU to conduct investigation, OPU/JV/HCU may use
various investigation tools to complete their investigation. For MAJOR incidents, the use of
Tripod Beta tool is very much encouraged and recommended. )

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4.1

General
The approach of tabulating events and then ordering them by date, time and place is an
essential stage in establishing the sequence of events towards the Hazard Event Target
(HET) diagram for the accident. Identifying the respective failed barriers / controls result in the
establishment of the core diagram.

4.2

Incident Investigation Trees

The construction of a diagram showing the connections between the various events and
conditions leading up to the incident - a TRIPOD Investigation Tree - has proved to be a
useful technique in the investigation process, especially for more complex incidents (see
Appendix 12).
Construction of a diagram of factors may not be necessary for less complex incidents, but the
technique of enquiry is still valid: "What prior events or conditions were necessary for this to
happen?"

ANALYSIS OF FINDINGS
The purpose of analysis is to establish the critical events and the underlying causes of the
incident such that corrective measures can be taken to prevent future incidents, and also to
understand the failures and weaknesses in management system that led to the incident. This
requires investigators to have a clear understanding of the cause and sequence of activities
and why one event or situation progressed to the next. It is recommended to carry out the
investigation and analysis concurrently, so that they can support and build on each other.
Many methods are available for analyzing the underlying causes of incidents, but some of
these do not recognize the concepts of latent (management) failures. Therefore, the use of
Tripod methodology to conduct analysis of HSE incidents especially for Major Incidents is
highly recommended.
Incident causation studies, particularly the Tripod research, clearly identify that an incident is
the end result of a chain of events. These can be identified at differing stages in the incident
causation sequence.
The incident investigation should not be restricted to the unsafe acts or active failures as this
will only conclude that human failures (driver, operator, drilling crew) caused the incident
("human error"). The Tripod theory has shown that unsafe acts do not occur in isolation but
are influenced by existing preconditions, which may originate from failures in the top level of
the organisation and line management. Such activities and decisions are removed in time and
place from the end-of-the-line operations, where the incidents occur. The so-called latent
failures may lie dormant within the system for a long time, and their adverse consequences
may only become evident when they combine with other factors to breach the system
defences. Detailed case studies reveal that latent rather than active failures are the
precursors of incidents. Tripod classifies these latent failures into General Failure Types
(GFTs) / Basic Risk Factors (BRFs).
Identifying and correcting these latent failures rather than merely correcting the active failures
induced by them (symptoms), is more effective in meeting the ultimate objective of the
investigation, namely to improve the overall HSE performance.
Identification of underlying causes and latent failures need not necessarily involve application
of the full Tripod methodology, but should apply the causation theory as proposed by Tripod
(See Fig. 2), involving a brief consideration of the GFT/BRFs.
See Appendix 12 for a summary of the Tripod methodology.

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Figure 2 Tripod Incident Causation Sequence

For the investigation and analysis of less serious incidents or Minor Incidents, other
methodology other than Tripod can be used but should include an analysis of factors such as
type of incident, type of injury, phase of operation or activity, cause of incident which provide
valuable input to an incident prevention program.
In all findings, either using Tripod or other tools, the final analysis should be presented or
categorized into 11 Tripod Basic Risk Factors (BRF). This is important as to provide
consistent analysis to all the findings. The definitions of BRF are given in Appendix 13 and
the details can be referred to in PTS 60.0504 Tripod Beta The Analytical Tool (Guideline).
6

IDENTIFICATION OF RECOMMENDATIONS
The investigation process should identify actions to prevent recurrence. This can best be
achieved by addressing the unsafe acts and unsafe conditions, and by identifying and
correcting the latent failures.
Not all causes can be completely eliminated, and some may be eliminated only at prohibitive
cost. Some recommendations will therefore be aimed at reducing the risk to a tolerable level,
while others will be aimed at improving protective systems (the defences) to limit the
consequences.
All recommendations should be in the form of measurable action items with clearly defined
action parties and a time scale for implementation.

INVESTIGATION REPORT

7.1

Compilation
The investigation report is a presentation of the findings and recommendations of the
investigation team. The report should be in a standard form (see Appendix 14). For more
complex incidents diagrams of the Incident Investigation Trees should be attached to give an
overview of the causation sequence (see Appendix 12).
Appendix 14 provides an outline of an investigation report.

7.2

Legal Assistance
When incident reports are being compiled that may be required by authorities outside the
company, it is strongly recommended that legal advice is sought in the preparation of the
report. Legal advice should also be considered if third parties, including other authorities than

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those directly competent in respect of the incident, request to be provided with copies of the
report. Each such request should be considered on a case by case basis taking into
consideration the potential risks and exposures for the Company, its directors and employees
for possible criminal or civil liability.
7.3

Management Review and Endorsement

Before completion, the investigation report should be reviewed at the appropriate
management level as a check on the completeness and quality of the investigation and to
obtain endorsement of the recommended actions.

DATA RECORDING
Key data from all incidents should be registered in a database to facilitate

preparation of performance reporting requirements to PETRONAS Group Companies

and/or local authorities
statistical analysis of incident data
causal/trend analysis.

For this purpose a database such as iHSE can be used.

Notification to PETRONAS Group Companies can be done by document transmittal or by
direct computer data transfer. At early implementation of iHSE, Incident Initial Notification will
be transmitted via fax.

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APPENDIX 12: INCIDENT INVESTIGATION TREES

The Incident Investigation Tree arranges the facts in a logical and sequential fashion. As far as is
possible these facts will consist of "date and time stamped" events and conditions known to exist at
the times and places involved. The process assists in identifying which facts are missing and
necessary to explain the causal sequence. The analysis identifies the critical events in the process to
discover the underlying causes. Investigation establishes the facts, analysis interprets them with a
view to prevention. Analysis may result in posing questions about events which require further
investigation.
An "event" is something which happened in the period being described, such as:

a decision made to act in a certain way

component failure
a rain squall.

An "event" may also be considered as a change of state.

A "condition" is a state which was present over a period of time, such as:

a wet road surface

a flammable atmosphere.

An "event" could be the start of a condition, e.g. a joint failure having created a flammable
atmosphere.
Not all of the events and the conditions described are faults. The full description of the circumstances
of an incident must include all normal factors so that decisions made and actions taken can be seen in
their correct context.
1.

CONSTRUCTION OF TREES
The incident event is the starting-point for constructing an investigation tree. Starting with the
incident itself, identify the prior events or conditions which were necessary for the incident to
happen (essential factors). Each factor can then be traced back in a similar way, identifying
further essential factors. The process of tracing back should be continued for each chain of
events to a point where it is considered to be outside the control or prevailing influence of the
Company.
Validation should establish that only factors which had any bearing on the incident are
included in the tree diagram. "Factors A, B (and C) were all necessary for event D to happen".
These should be joined by an 'and' gate. If removal of a factor is seen not to affect the
outcome it cannot be considered an essential factor.
If several alternative factors could have contributed to the next event, then these should be
combined through an "or" gate and may highlight an area where further investigation is
required.
An ongoing condition can appear more than once in an investigation tree, as a contributory
factor to events separate in time.
Care should be taken to describe facts correctly. For example, "failure to wear protective
equipment" may imply that there was a rule which was broken. Leads to follow from this fact
would be in the areas of supervision and motivation. The statement "no rule for wearing
protective equipment" would lead to areas of policy and procedures.
From the finished tree it should be possible to see where the operation deviated from its
desired course, and identify not only the specific actions of people involved but also areas of
weakness in a company's safety management.
The example below shows an investigation tree identifying remaining leads to be followed.

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2.

EXAMPLE OF INCIDENT INVESTIGATION TREE

Drowning Accident
Summary
Four men, working on construction of a drilling location, were returning to their camp by
swimming across a 6-metre-wide creek. Due to the strong current, all of them got into
difficulties. Three managed to reach the opposite bank, but the fourth failed and drowned. His
body was recovered 24 hours later.
Background
Four men had been assigned to clear a track for a water line between a new drilling location
and a nearby creek. The new location was across the creek from the engineering base camp.
To get to the worksite from base, crews could either cross the creek by canoe or walk around
via an upstream bridge, which would take them about an hour and a half.
On the day of the accident, the four men had been able to get a local canoe to ferry them
across in the morning. At about 11.30, being hungry, they decided to return to the camp for
lunch. They waited a short while for a canoe to pass, but none came. Their supervisor was
not there, and they did not want to lose time by waiting, so they decided to swim across the
creek. The water was flowing quite fast, but the creek was only six metres wide and they all
had life-jackets.
Due to the current, they all experienced difficulty in swimming. Three men managed to make
it to the other bank, exhausted, but they could not locate their companion (Mr. X). The creek
was muddy and full of debris.
Mr.X's body was recovered by villagers some 24 hours later. It was found at the bottom of the
creek, some 50 metres downstream of the crossing point. His life-jacket was still attached.
Result of the Investigation
The civil engineering contract specified that the Contractor was responsible for
accommodation, feeding and transport of field crews.
The labour subcontractor was given a daily allowance to cover transport. He did not
provide a canoe on stand-by, but there were usually enough local canoes passing for his
crews to obtain lifts across the creek.
Life-jackets of local manufacture had been issued for use when working by water. Due to
recent rains, rivers and creeks were high. Instructions had been given to wear life-jackets
"at all times".
Life-jackets had been in use for about three months, but many were in poor condition,
with securing tapes broken or missing and polystyrene floatation blocks
broken/compressed.
Neither the Company nor the Contractors had prepared a river crossing procedure.
There was no rule forbidding swimming; contractor management considered that some
swimming was unavoidable.
It was the understanding that all men could swim, but no swimming tests had been held,
so individual competence had not been verified.
The subcontractor's labour were paid on a piece-work basis.
Construction crews were split up into groups of 3 to 4 men, one supervisor looking after 5
or 6 groups.

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Further Investigation Leads

Further leads to follow in order to complete the investigation tree (refer to the numbers on
Figure 3).
1. Controls in piece work contract to make sure that safe working practices were
maintained.
2. Feeding arrangements for crews at worksites.
3. Transport safety provisions:

4.

the main contract

the labour subcontract.

Monitoring of transport adequacy and safe operations:

by main Contractor

by the Company.

5. (a) Identification of hazardous tasks in the Company safety plan

.

(b) Operating and safety procedures for the project.

6. Discussion of the hazards of swimming in safety meetings/briefings.

7. (a) Contractor supervisor levels
.

(b) Supervisor's safety training

(c) Audits of Contractor supervisory effectiveness.

8. Dissemination of information on effect of heavy rainfall.
9. Verification of swimming skills.

10. Life-jacket inspection and maintenance.

11. Approval of life-jacket design as work vest or life-saving appliance.
12. Suitability of life-jacket materials and fabric for daily rough usage.

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Figure 3 - Incident Investigation Tree

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APPENDIX 13: BASIC RISK FACTOR (BRF) DEFINITIONS

GFT /
BRF
Initials
DE

Short
Definition
Design

Single Sentence
Definition

Full Definition

The creation of the

optimum ergonomic
solution to a particular
set of needs or
circumstances

The creation of an appropriate* engineering

solution to a specific set of needs or
circumstances, most often for the interface
between equipment and people. A design
failure will most often be recognisable when
there is a significant difference between the
way the designer intended something to be
used and the actual use to which it is put in
practice. It is often created when the
designer is given a poor or inappropriate
specification or where a piece of equipment
is used in the wrong context of place.
* In engineering terms, an ALARP (as low
as is reasonably practicable) solution would
be appropriate

HW

Hardware

Tools, equipment and

components to work
correctly, efficiently
and reliably within their
specified operational
limits

The quality of materials used in tools,

equipment and components insofar as it
affects their ability to operate reliably,
efficiently and effectively within the limits
laid down by the designer, throughout their
lifecycle.

PR

Procedures

A clear, formal
description of tasks to
be undertaken at the
operating interface
between people and
equipment

A formal, step by step description of the

safest and most efficient way of carrying out
a particular task or operation.
It will incorporate the accumulated craft
wisdom and practical knowledge gained
through operating experience.

Popular
(Colloquial)
Definition
Applying
common sense
to equipment
and machinery
control layout
and positioning!
Or
Remembering
that equipment
and machinery
control layout
and positioning
has to be used
by human
beings!
Is the bit of kit
right for the job?

In the ideal
world, a
foolproof,
competent
persons guide
to the job.

It will be in a clear, unambiguous form that

can be understood and utilised by a
competent person who may not, however,
have recent experience of the task.
EC

Error Enforcing
Conditions

Conditions,
circumstances and
situations which will
significantly increase
the chance that errors
or violations will occur.

A serious circumstance or situation where

an inadvertent error or deliberate violation
is more likely to occur and have a serious
consequence; in the presence of hazardous
conditions there is a significantly enhanced
risk of injury or damage.
Error enforcing conditions may be
environmental (e.g. weather, social (e.g.
over-confidence) or physical (e.g.
tiredness).

Flying by the
seat of your
pants is not the
best method of
dealing with
unexpected
problems or
opportunities

An error enforcing condition is usually

triggered by a change from the norm, where
a persons ability to function in his/her
environment is compromised, and where
existing best practise procedures and
habits are likely to be ignored or changed.
HK

House Keeping

The maintenance of a
clean and tidy
workplace

The provision and management of the

resources and systems to keep a workplace
clean and tidy and remove waste on a
continuous basis.

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A place for
everything and
everything in its
place.

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Housekeeping becomes a latent failure

when it is neglected for a period of time and
when there is an awareness of such neglect
and nothing is done. Housekeeping
performance will only break down if:
1) Management make site visits, are aware
of a poor performance but fail to take
remedial action.
2) Management make site visits but are
hoodwinked into thinking that there are
no problems.

TR

Training

Provision of
appropriate instruction
to develop
competence to enable
everyone to carry out
their jobs safely to the
required standard.

IG

Incompatible
Goals

The increase in risk

arising from the
conflict between
different and
unbalanced priorities.

3) Management do not make site visits at

all.
Development of competence in procedures,
equipment and systems to enable safe
working practises to be undertaken
efficiently; this will be through
coaching/mentoring as well as through
formal training courses. Training also
includes the consideration of the
appropriateness of qualifications and the
management of a system for the checking
of those qualifications.
Conflict between the different priorities and
goals of individuals, groups (departments)
and the organisation can create latent
failures, particularly when management
give little or no guidance on the priorities.

Have you got

the knowledge
and skill?

Keeping on the
tightrope when
different weights
keep getting
added to your
balancing pole.

The conflicting goals that are inevitably

inherent in any organisation are particularly
likely to generate accidents under extreme
time pressure.
Errors are also likely when employees are
forced to continuously choose between
optimal working methods and the pursuit of
production, financial, political, social and
individuals goals.
CO

Communication

The transmission and

understanding of
essential information

The transmission of clear, unambiguous

and intelligible information to the right
person at the right time to ensure the safe
and effective functioning of all or part of the
organisation. Communications can break
down if:

Providing the
right information
to the right
person at the
right time.

1) The necessary communications systems

or channels do not exist.
2) The channels and systems exist but the
necessary information is not sent or is sent
too late to be of use.
3) The information is sent at the right time
but is misinterpreted or ignored by the
recipient.
OR

Organisation

The implications for

safety management
from the way the
company is structured
and conducts its

67

The structure of the company, its business

philosophy, organisational processes and
management strategies should prevent
safety responsibilities becoming poorly
defined and warning signs being

Dont let it slip

between the
cracks. It is
your
responsibility!

PTS 60.0501
AUGUST 2010

MM

business

overlooked.

Maintenance
Management

Systematised
management to
ensure correct
maintenance of
processes, plant,
equipment and tools

The development and use of appropriate

management systems to maintain the
technical integrity of all processes, plant,
equipment and tools. The choice of
maintenance strategies should be suited to
the actual environment and sometimes
allowing items to breakdown may be the
preferred option! (The execution of
maintenance is considered in GFT/BRFs
Error Enforcing Conditions, Procedures,
Design, Hardware and Communication)

Defences

Mitigation of the
consequences of
human and/or
technical failure

Defences are what stop you getting hurt

when all else has failed - they are the
barrier between the target (you!) and the
hazard. Defences should provide layered,
in depth protection to warn of and guard
against the consequences of human or
technical failure. Each layer comes into
operation on the failure of its predecessor;
this defence in depth sequence should
have the following components:

DF

68

1)

Detection/warning

2)

Control and interim recovery to a safe

state

3)

Protection and containment

4)

Escape

Recognising
that prevention
is better than
cure

The Last
Chance Saloon
- defences
should only
become active
in the last
stages before
an accident
occurs.

PTS 60.0501
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APPENDIX 14: INCIDENT INVESTIGATION REPORTS & PRESENTATION MATERIAL FORMAT

This appendix contains a brief description of the key elements of a written investigation report.
General recommendations to consider in preparing the report are:

the report should be factual, concise and conclusive

interpretations of findings should be based on the facts as identified in the investigation

unsubstantiated speculation should be avoided at all times

assessment of underlying causes should be made, based on an analysis of the findings

where events or conditions are listed, that are not critical for the incident to have occurred,
this should be clearly indicated

the report should be readable as a stand alone document, references to other documents not
open to inspection by others i.e. the public, should be avoided

previous drafts of the report should be destroyed

a paper trail of the documents relevant to the incident and the report should be established.

14.1

SPECIFICATION OF AN INCIDENT INVESTIGATION REPORT

Abbreviation
Table of Content
Executive Summary
A brief summary of the report, giving the background of the Incident, a description of the
Incident, description of injuries, damage and loss, and outlining the main facts, principal
causes identified, and remedial measures taken
Introduction
Brief Incident description
Investigation team members
Investigation methodology
Background
Facilities information or project background
Other relevant facts for the facilities
Description of incident
A statement of the facts immediately surrounding the incident, covering the period from the
initiating events until the situation was under control and identifying, where possible, the
sequence of events. In this context photographs, maps or drawings should be used as
illustrations to support the narrative.

Details of incident Time, Place and Date

Details of injured person
status, i.e. company employee, contractor employee, or third party (specified)
name, age, whether employee, contractor, or third party, position held, time in
that position
length of service (company and area)
nationality and family status
details of injuries, in a form understandable to non-medical readers (medical

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reports can be attached as appendices).

Events leading to incident

A short narrative which sets the scene of the Incident:

description of the operation in progress

preparations made for the work (work procedures, instructions, permits,
supervision)
personnel and equipment involved
environmental conditions
activities taking place at the scene of the incident
activities of key persons prior to the day of the incident that could have affected
their actions

Sequence of events

Impact of incident
Actual impact on people, asset, environment, reputation
Results of the incident investigation
This section should demonstrate that the investigation was carried out in sufficient depth to
support the conclusions that follow. It should include, where relevant, references to:

environmental conditions
condition of equipment and facilities, known deficiencies, positioning, operating mode,
etc
procedures relating to the operation
pertinent information concerning the principal operators and supervisors (e.g. training,
experience,
hours into shift and days into tour)
work instructions and communications
records and documentation
information derived from the nature of the damage
witnesses' statements
medical information (state of health)
factors affecting alertness or judgement (e.g. fatigue, social pressures, alcohol,
medication or drugs)
working conditions
survival aspects
results of special investigations and tests
rescue and damage containment activities
emergency response and recovery activities

Conclusions
This section should include the results of the analysis of the findings, identifying the
immediate and underlying causes and commenting on the effectiveness of rescue and
damage containment activities where appropriate.
Conclusions based on circumstantial evidence should be highlighted as such.
The underlying causes or root causes should be presented based on 11 BRF.

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Recommendations to avoid Recurrence

Recommendations should be provided as immediate (complete within a month), short term
(complete within 3 months) and long term
Recommendations should identify corrective measures for as many of the listed causes (in
the Conclusions) as possible and may be related to:
eliminating the causes
minimising possible consequences
improving rescue or damage containment measures
emphasising that all causes identified should be eliminated.
Action parties and time schedules for implementation should be identified
Consequence Management
Consequence management actions e.g. show cause letter or other appropriate disciplinary
actions which have been or need to be taken shall be included in the investigation report.
References
Any other pertinent information considered necessary for the understanding of the report. This
should include, among others, photographs, maps, drawings, and interview record to
supplement and clarify the written report.
Use of standard report forms
Many companies have a standard incident report form. Even though, a standard form is not essential,
it can have the advantage of setting out the minimum reporting needs in a logical order.
On the other hand, standard forms can also have disadvantages, some of them caused by form
design. A review of the way in which forms are completed may highlight areas where they are
deficient. It must also be borne in mind that in the case of complex incidents, a standard form will
seldom be adequate.
Many standard incident report forms do not differentiate sufficiently between the elements of incident
notification, investigation findings and recommendations. These elements could well be completed by
different people, and should be kept clearly segregated.
One approach is to have a short basic Accident Notification form, and a longer Investigation Report
containing detailed results of the investigation.
For PETRONAS Group, the following form should be used as a standard report for Minor Incident.
Any details to the investigation should be attached to the form. For Major Incident, the Final Report
should consist of all the subjects described above.
Not all forms are self-explanatory, and there should be clear guidelines available to ensure common
understanding of information requirements, e.g. clear differentiation between "description of event"
and "incident cause".
Allocation of space is a very critical part of form design, and insufficient space may lead to lack of
detail being recorded.
The investigation report with appropriate appendices should "stand alone", i.e. it should contain all
relevant information necessary for reviewing the incident.

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For MINOR INCIDENT, the following Incident Investigation Report should be used.
MINOR INCIDENT INVESTIGATION REPORT
Team Members
Leader
:
Member(s)
: (1)
: (2)
: (3)
Report Status:

OPU:
DIV:
Incidents Location:
Incident Date:
Incident Time:

Initial
Final

General Information
Reporter
:
Designation
:
Department
:
Immediate Supervisor:

Company Incident
Contractor Incident
rd
3 Party / Public

Reportable
Recordable

Authorities Informed
Police
Fire Department
DOE
DOSH
Others; Please specify:
1.0 Nature of Incident

Injury Type Incident

Fatality,
Lost Time Injury,

Non-Injury Type Incident

Fire / Explosion
Property Damage
Cost (RM):
Hydrocarbon Release
Volume:
Production lost:
Business Interruption, Down time:
Transportation; Please specify:
Near Miss
Theft
Cost (RM):

Environmental Non-Compliance
Waste disposal
Effluent spill
Emission to Air
Discharge oil/chemical
Volume released
:
Volume recovered
:

Implication / Impact & Rating

People
1 2 3 4 5
Asset
1 2 3 4 5
Environment 1 2 3 4 5
Reputation 1 2 3 4 5
Security
1 2 3 4 5

Activity Involved :

Incident Direct Cause Classification:

No. of fatality:
No. of injury:
No. of hospitalized:
Workday lost: day(s)
Restricted Work Case
Medical Treatment
First Aid
Occupational Illness

2.0 Description of Incident: What, When, Where, Who, Why, How. Additional space for
description / sketches on Attachment page

3.0 Mitigation Action Taken:

4.0 Immediate Cause(s): Unsafe Acts and Unsafe Conditions

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MINOR INCIDENT INVESTIGATION REPORT

OPU:
DIV:

5.0 Root Cause: Inadequate procedures, program, training, communication.(11 Tripod BRFs)

6.0 Immediate Corrective Action: control, contain, treat

Person In-Charged:
7.0 Permanent Corrective Action:

Target Completion Date:

Person In-Charged:
8.0 Management Control Action:

Target Completion Date:

Person In-Charged:

Target Completion Date:

Signature

Name

Date

Prepared by:
Reviewed by:
Approved &
Submitted by:

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MINOR INCIDENT INVESTIGATION REPORT

ATTACHMENT FOR DESCRIPTION OF INCIDENT
Insert graphic or description text

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14.2

TEMPLATE FOR AN INCIDENT INVESTIGATION PRESENTATION MATERIAL

The presentation material of any incident investigation shall consist of the following slides:
1. Front page
Title
Purpose
Date

2. Presentation Outline Titles

Incident Summary
Background
Sequence of event
Investigation Findings
Conclusion
Recommendation

3. Incident Summary
Incident Details (What, Date & Time, Location, Impact, Immediate Action)
Investigation Team Members & Resource Person

4. Background
Background which may/ may not include photos or video
Details of casualty and/or victim (s)

5. Sequence of events
Times & events

6. Investigation Findings
Based on HSEMS elements & sub-elements
Causual tree / why-why
Tripod-Beta

7. Conclusion
Direct cause
Underlying cause (s)

8. Recommendation
Prioritize action plan
Time frame for action closure
Action parties
Report on closure status to Head, GHSED on quarterly basis
Action item to be tracked in iHSE

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APPENDIX 15: INVESTIGATION OF NON ACCIDENTAL DEATH

Where non-accidental death occurs to a person who is currently employed by, or on contract to, the
OPU/JV/HCU, records of medical pre-employment checks, periodic medical checks, information about
the work and work conditions preceding the death should be investigated. This also applies to nonaccidental deaths outside normal working hours.
The objective of this investigation is to ascertain whether the cause of the death is work-related 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 OPU/JV/HCU statistics.
In order for the OPU/JV/HCU to determine whether this is the case, the following questions need to be
addressed as a minimum:

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

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

Are there any pre-existing medical conditions?

Has the individual been declared medically fit to carry out his/her normal duties in compliance
with OPU/JV/HCU standards?

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

Had the individual been recently referred to a Doctor?

Where death occurred within the OPU/JV/HCU fence, were the OPU/JV/HCU Medical
Emergency Response (including First Aid, Medical Treatment and Medevac) procedures
suitable and complied with?

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APPENDIX 16: SPECIAL SITUATIONS

a)

FATALITIES AND NON-ACCIDENTAL DEATHS

The classification of Fatalities as work-related is ultimately the responsibility of the Group
HSE although the OPU/JV/HCU will propose a classification in its investigation report.
Non-accidental deaths involving OPU/JV/HCU staff, Contractor staff or third parties that may
be work-related shall be reported and investigated before a classification is attempted.

b)

THIRD PARTY FATALITIES

All third party fatalities are to be reported if they are the result of work-related activities. They
are reported and investigated in line with the procedure given above.
Third party fatalities will be included in the statistics if the incident resulted from a failure of
management controls that should have been in place. Third party fatalities caused solely by
the behaviour of the third party when all reasonable OPU/JV/HCU and Contractor
management controls were in place, can be proposed to the Group HSE Division as not to
be included in the statistics.
Final classification, on the basis of the investigation report, is the responsibility of Group HSE
Division.
All work-related third party fatalities resulting from assault, sabotage and theft are to be
included in the statistics.

c)

LOST TIME INJURIES (LTI) AND RESTRICTED WORK CASES (RWCS)

Although Lost Time Injury Frequency (LTIF) is regarded within the industry at large as the key
safety performance indicator, the low numbers of incidents reported are often not statistically
significant at the Company level. Moreover, the undue stressing of LTIF, can often lead to
debate on whether the incident should be classified as RWC or Medical Treatment Case
(MTC) rather than LTI. For performance monitoring it is now strongly recommended that
Companies use Total Reportable Case Frequency (TRCF) as the prime measurement of
safety performance, in addition to reporting LTIF.
The decision as to whether an incident is classified as a Restricted Work Case or a Lost
Workday Case should, if possible, be reached after consultation with a OPU/JV/HCU medical
adviser.
Group HSE Division should be consulted before a decision is made.

d)

OCCUPATIONAL ILLNESS
An Occupational Illness is defined as any work-related abnormal condition or disorder, other
than an injury, which is mainly caused by exposure to environmental factors associated with
the employment. It includes acute and chronic illness or diseases which may be caused by
inhalation, absorption, ingestion, or direct contact.
Whether a case involves a work-related injury or an Occupational Illness is determined by the
nature of the original event or the exposure which caused the case, not by the resulting
condition of the affected employee. An Injury results from a single event or from a single
instantaneous exposure in the work environment. Cases resulting from anything other than a
single event or exposure are considered Occupational Illness.
The key performance indicator for Occupational Health incidents is Total Reportable
Occupational Illness Frequency (TROIF).

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Examples to clarify the boundaries between Occupational and non-Occupational Illness, and
between Injury and Illness, are given in Appendix 2. Having determined that an illness is
occupational the Company should categorise it according to the classification in Appendix 5.
e)

ENVIRONMENTAL INCIDENTS
The definition of an Environmental Incident is "an unplanned event or chain of events that has
or could have a negative impact on the environment".
OPU/JV/HCUs are advised to develop its own specific guidance on the type and size of
spills and releases that would fall into consequence rating 4 or 5 of the Incident Classification
Criteria. Such guidance should take into account the specific environmental sensitivities in the
area of operation.

f)

REPUTATION INCIDENTS
The definition and classification of the severity follows the Incident Classification Criteria and
the reporting of such incidents is as Section 4. The requirement to mobilise the PETRONAS
Group Crisis Management Plan needs to be evaluated with reference to it.
OPU/JV/HCUs are advised to develop their own specific guidance on the type of Incidents
that could trigger adverse attention to the OPU/JV/HCUs operations and which would place it
into rating 4 or 5 of the Incident Classification Criteria. Such guidance should take into
account the specific local circumstances and sensitivities.

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