Incident Classification and Reporting

Introduction
INCIDENT CLASSIFICATION,
INVESTIGATION AND
REPORTING
The companies belonging to the Royal Dutch/Shell Group of companies are separate and distinct entities,
but in this document the collective expressions “Shell” and “Group” are sometimes used for convenience in
contexts where reference is made to the companies of the Royal Dutch/Shell Group in general. These
expressions are also used where no useful purpose is served by identifying the particular company or
companies.
This document is prepared by Shell International B.V. (SI) as a service under arrangements in existence with
companies of the Royal Dutch/Shell Group; it is issued for the guidance of these companies and they may
wish to consider using it in their operations. Other interested parties may receive a copy of this document for
their information. SI is not aware of any inaccuracy or omission from this document and no responsibility is
accepted by SI or by any person or company concerned with furnishing information or data used in these
guidelines, for the accuracy of any information or advise given in the guidelines or for any omission from the
guidelines or for any consequences whatsoever resulting directly or indirectly from compliance with or
adoption of guidance contained in the guideline even if caused by a failure to exercise reasonable care.
The copyright of this document is vested in Shell International B.V., The Hague,
Netherlands.
All rights reserved.
February 2002
HEALTH, SAFETY AND ENVIRONMENT ADVISERS PANEL
Incident Classification, Investigation and Reporting, Issue 2.0, February 2002

Introduction

Table of Contents
Introduction
1. MANAGEMENT SUMMARY 1
1.1 Purpose and Scope 1
1.2 Group Standards 2
2 Classification of Incidents 3
2.1 Work Related Activities 3
2.2 Injuries 4
2.3 Illnesses 4
2.4 Incidents Resulting in Asset Damage, Environmental Impact and/or Impact on
Company Reputation 4
2.5 Near Misses 5
2.6 Potential Incidents 5
2.7 High Risk Incidents 5
3 Investigation of Incidents 6
3.1 Responsibilities and Competence 6
3.2 Extent of Investigation 6
3.3 Investigation Process 6
3.4 Establishing the Sequence of Events 7
3.5 Analysis of Underlying Causes and Weaknesses in Management System 7
3.6 Incident Report and Follow up 8
3.7 Communication of Lessons Learned 9
4 Reporting of Incidents 10
4.1 Reporting Company 10
4.2 Reporting of Significant Incidents 11
Appendix 1: Definitions and Explanation of Terms 13
Appendix 2: Incident Classification and Reporting Flow Chart 18
Appendix 3: Medical Treatment Cases and First Aid Cases 19
Appendix 4: Distinguishing between Injuries and Illnesses, and Determining

whether Illnesses are Occupational 21
Musculo-skeletal Conditions including Back Problems 21
Repetitive Strain Injury (RSI) 23
Work Related Stress 24
Burns 24
Dermatitis 25
Animal Bites and Insect Stings 25
Heart Attacks 25
Infectious Diseases 26
Common Subjective Symptoms 26
Food Poisoning 26
Noise Induced Hearing Loss 26
Eye Problems 26
Aggravation of an Existing Physical Deficiency 27
Pre-existing Conditions 27
Infected Laceration 27

Introduction
Table of Contents
Reaction to Medical Treatment 27

Recurrence of Symptoms 28
Medical Verification by a Medically Qualified Person 28
Individual Susceptibility 28
Permanent or Temporary Transfers 28
Overexposure to Health Hazards 29
Appendix 5 Classification of Occupational Illness 30
Appendix 6 Asset Damage - Examples 32
Appendix 7 Environmental Impact - Examples 33

Atmospheric Emissions 33
Oil and Chemical Spills 33
Complaints 34
Non-compliances 35
Appendix 8 Reputation Impact - Examples 36
Appendix 9 Incident Investigation Guidance 37

Conducting Interviews 37
Inspecting the Location 37
Collecting Background Information 38
Fact Finding 39
Records and Procedures 39
Special Studies 40
Conflicting Evidence 40
Appendix 10 Sequentially Timed Event Plot - Example 41
Appendix 11 Incident Report Layout for a Significant Incident 42
Appendix 12 Work Related Activities – Guidance and Examples 44

Transportation of Personnel 44
Working from Home 45
Working Away From Home 45
Transportation of Goods and Equipment 46
Transportation of Product 46
Injuries during Training 47
Meal Period Illnesses 47
Fitness Centre 48
Entertainment of or by Customer, Supplier or other Business Contacts 48
Recreation and Social Events 48
Acts of God and Wilful Acts 48
Horseplay 49
Appendix 13 Procedure for Reporting and Review of Significant Incidents 50
Appendix 14 Exposure Hours - Examples 52

Management Summary
1 MANAGEMENT SUMMARY
1.1 Purpose and scope
The Shell Group HSE policy requires that every Shell Company “has a systematic
approach to HSE management designed to ensure compliance with the law and to
achieve continuous performance improvement” and “sets targets for improvement and
measures, appraises and reports performance”. An essential feature of the systematic
approach and continuous performance improvement is the reporting of incidents, so that
they can be investigated, lessons learned, and performance monitored.
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
This document provides guidance on the classification, investigation and reporting of

incidents which result in injury or illness, and in damage to assets, the environment or
company reputation. It also addresses incidents that had no adverse outcome, i.e. near
misses. It sets out the rules for the reporting of incidents by Shell companies and joint
ventures. This revision replaces the Group Incident Classification and Reporting Guide
(1997).
The reasons for revising this guide are:

• To embed the concept of near misses and potential incidents, and the application of
the Risk Assessment Matrix in the process of classifying, investigating and reporting
incidents;
• To provide more detailed guidance and examples of incidents that result in damage
to assets, the environment and company reputation;
• To align the guidance on classification of illnesses and injuries more closely with the
Occupational Safety and Health Association (OSHA) classification system;
• To incorporate the guidance needed to classify and report occupational illnesses,
including alignment with the Group Minimum Health Standards, thus allowing the
Guide for Health Performance Reporting (1993) to be withdrawn;
• To incorporate and update the guidance on incident investigation and analysis, thus
allowing the Incident Investigation and Analysis Guide (1993) to be withdrawn;
• To achieve alignment between this guide and the Group publication HSE
Performance Monitoring and Reporting (2000) that is currently being revised.
Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 1

Introduction Summary
Management
1.2 Group Standards
The Group Procedure for an HSE Management System applies to all companies that are
under Shell’s operational control. This procedure requires that “all incidents and near
misses with significant actual or potential consequences shall be thoroughly investigated
and reported”.
This section details the standards and procedures that are mandatory for all Companies:
• Companies shall implement processes for identifying and logging all incidents that
occur in their activities. They shall classify the incidents in terms of actual
consequences and risk rating, applying the Risk Assessment Matrix (RAM);
• Companies shall investigate all significant incidents, i.e. those with actual
consequences to the company which rate 4 or 5 on the RAM, to establish both
immediate and underlying causes and weaknesses in the HSE management system.
The investigation shall include a Tripod analysis. They shall recommend actions to
prevent recurrence and to improve effectiveness of the HSE management system.
They shall report the findings of their investigation and their action plan to the
business. The Procedure for Reporting and Review of Significant Incidents is detailed
in Appendix 13;
• Companies shall investigate all incidents that have a high risk rating on the RAM, to
establish the immediate and underlying causes and weaknesses in the HSE
management system. They shall recommend actions to prevent recurrence and to
improve effectiveness of the HSE management system. When the investigation reveals
significant learning potential (see section 3.7) they shall report the findings and
learning to the business.

Introduction of Incidents
Classification
2 CLASSIFICATION OF INCIDENTS
Incidents are unplanned events or chains of events that have, or could have, resulted in
injury or illness or damage to assets, the environment or company reputation. This
section describes how to determine if an incident is work related and then goes on to
describe the various types of impact of incidents. Definitions and explanations of the
terms used are presented in Appendix 1 and a flowchart of the process of classifying
incidents is given in Appendix 2. Examples of the different types of impact of incidents
are given in Appendices 3 to 8.
2.1 Work Related Activities
Work related activities are defined as those activities for which management controls are
in place, or should have been in place. Incidents occurring during such activities must
be reported and will be included in performance statistics.
For consistency in the reporting practices of Group companies, the following activities
are considered to be work related, as they are susceptible to incidents with significant
impact, for which company controls should be in place:
• All work by company personnel;
• All work by contractor personnel on company premises;
• All work by contractor personnel on non-company premises for which it is
concluded on the basis of risk considerations that company and contractor
management controls are required.
For company personnel work includes overtime, attending courses, conferences and
company organised events, business travel, field visits, or any other activity where the
employee’s presence is expected by the employer.
For contractor personnel, the same activities are included when they are executed under
a contract on behalf of the company. Contractor includes all sub-contracted activities.
Where it is impossible or inappropriate for the company to seek to apply management

control on a contractor, exceptions may be justifiable. Examples may be found in areas
where contractor services are not dedicated to the company, for example:
• 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 or products to company locations by a contractor who is also
employed to deliver goods or products to other companies during the same journey;
• Customer collection of company products, where the vehicle and drivers are under
the control of the customer.

Classification
For these exceptional situations the company should make a conscious, risk based and
documented decision whether or not to maintain management controls and include
incidents in performance reports.
Appendix 12 provides further guidance and a number of examples to illustrate what are
work related activities.
2.2 Injuries
The various terms are defined in Appendix 1 and guidance on the types of Medical
Treatment Cases (MTC) and First Aid Cases (FAC) is given in Appendix 3.
The potential consequences of injuries should be assessed on the RAM as described
in 2.4.
2.3 Illnesses
The procedure to determine whether or not an illness is occupational is detailed in

Appendix 4. Examples to clarify the boundaries between occupational and non-
occupational illnesses, and also between injuries and illnesses, are also given in
Appendix 4. Having determined that an illness is occupational it can then be categorised
into type of disorder or disease according to the classification in Appendix 5.
Occupational illnesses are not classified into severity classes, in the way that injuries are
classified into LWC, RWC, MTC and FAC. All identified occupational illnesses are
included in total reportable occupational illness data. The key performance indicator for
occupational illness is Total Reportable Occupational Illness Frequency (TROIF).
The potential consequences of illnesses should be assessed on the RAM as described

in 2.4.
2.4 Incidents Resulting in Asset Damage, Environmental Impact and/or

Impact on Company Reputation
Incidents resulting in asset damage, environmental impact and/or impact on company

reputation are not normally classified into severity classes in the same way as injuries.
However, the actual consequences and the (potential) risk rating should be assessed
using the RAM, so as to decide the level of investigation, follow up and reporting. Many
incidents have impacts in more than one category, e.g. asset damage and company
reputation, in which case the highest RAM rating determines the extent of investigation
and follow up.

Classification
2.5 Near Misses
Near misses are incidents that under slightly different circumstances could have caused
illness, injury or damage to assets, the environment or company reputation, but did not
(incident has occurred).
Overexposure to hazardous chemicals, noise and other health hazards should be
considered as near misses when the exposure did not result in an identified illness.
Companies should encourage the reporting and analysis of near misses as they provide a
valuable source of learning that can be applied to prevent future incidents.
2.6 Potential Incidents
Potential incidents are unsafe practices or hazardous situations that could result in an
incident (incident has not occurred).
Potential incident data is frequently collected in the course of work-site inspections,

unsafe act auditing, management walks and through incident or near miss reporting
systems.
Companies should encourage the reporting and analysis of potential incidents as they
provide a valuable source of learning that can be applied to prevent future incidents.
2.7 High Risk Incidents
High Risk Incidents (HRIs) are incidents for which the combination of potential
consequences and probability are assessed to be in the high risk (red shaded) area of the
RAM. HRIs can be incidents that result in injuries, illnesses or damage to assets, the
environment or company reputation, or they can be near misses.
HRIs should be thoroughly investigated and the lessons learned applied to prevent future
significant incidents. See also section 3.7.

Investigation
3 INVESTIGATION OF INCIDENTS
3.1 Responsibilities and Competence
Investigation of incidents is a line responsibility. All investigations should be led by or

sponsored by a line manager or supervisor. HSE and other specialists should be
employed as required in a support or facilitating role.
When conducting a detailed investigation and Tripod analysis, it is recommended that

the investigation team should include a competent Tripod facilitator. Each business
should develop competence criteria for Tripod facilitators, e.g. a person who has
attended a Tripod facilitator training course or has experience in applying the Tripod
methodology to the analysis of incidents.
Incidents occurring during activities controlled by contractors should be investigated by

the contractor, supported where necessary by company HSE and other specialist advisers.
The incident investigation report submitted by the contractor should be reviewed and
agreed by the company.
3.2 Extent of Investigation
The extent of investigation of incidents should be based on a consideration of:

• Actual consequences. Significant incidents should be thoroughly investigated and the
findings analysed by the Tripod method. In addition, local legislation may prescribe
the level of investigation and reporting of fatalities;
• Risk rating as determined by the RAM. The Shell HSE Advisers’ Panel publication Risk
Assessment Matrix (1999) gives guidance on the investigation team composition and
level of reporting for low, medium and high risk incidents.
3.3 Investigation Process
The investigation should be carried out as soon as possible after an incident. The quality
of evidence will deteriorate rapidly with time, therefore delayed investigations are
usually not as conclusive as those performed promptly.
The investigation should include the following activities:

• Conducting interviews;
• Inspecting the location and gathering physical evidence;
• Collecting background information;
• Fact finding;
• Reviewing records and procedures;
• Conducting specialist studies;
• Resolving conflicts in evidence.

Investigation
Guidance on these activities is provided in Appendix 9. The checklists can be used as a

ready reference before starting on an investigation.
3.4 Establishing the Sequence of Events
Documenting the sequence of events is a crucial step that provides the starting point for
analysis of underlying causes. A number of techniques are available to help visualise the
sequence of events.
3.4.1 Timeline
A timeline is simply a list of the events in chronological order. For straightforward
incidents a timeline and narrative will suffice as a description of the sequence of events.
3.4.2 Hazard-Event-Target (HET) trios

The Tripod Beta methodology applies linked HET trios to describe the sequence of events
before and after an incident. It is described in detail in EP 95-0321 Tripod Beta, which is
available on the Exploration and Production web site at:
http://sww.siep.shell.com/hse/index.htm?target=/hse/safe/tripod.htm.
3.4.3 Sequentially Timed Event Plot (STEP)

A STEP identifies the actions of key “actors” in the incident and plots them against time.
The “actors” can be people, vehicles, items of process equipment, process conditions
etc. The scale of the time axis is normally not linear, but varies to suit the interval
between events. Each event is described in terms of date, time, actor and action.
The value of a STEP is that it enables a visual representation of the sequence of events to
be shared by investigation team members and witnesses. It focuses the investigators on
agreeing the sequence of events before starting to analyse the causes. A STEP is
amenable to a white board and post-it technique. STEP is particularly powerful in
providing an overview of complex process incidents.
An example of a STEP diagram is shown in Appendix 10.
3.5 Analysis of Underlying Causes and Weaknesses in Management System
The purpose of this analysis is to establish the underlying causes of the incident, so that
actions can be taken to prevent recurrence, and also to understand the failures and
weaknesses in management systems that led to the incident. Although this analysis is a
separate activity from investigation of the incident, 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 analysing the underlying causes of incidents, but some
of these do not recognise the concepts of latent (management) failures. The method
recommended in the Shell Group for analysis of HSE incidents is the Tripod
methodology. Shell businesses and business units apply two variations of Tripod.

Investigation
3.5.1 Tripod for Understanding Incidents

This variation combines one of the techniques outlined above for documenting the
sequence of events, together with the Tripod theory of incident causation, including
“caused by” and “leads to“ guides, to establish the latent failures. The Tripod tree is
normally built using a white board and post-it technique, and the final tree is
documented in a spreadsheet.
Details of this method are available from Shell Global Solutions, OGCH/1.
3.5.2 Tripod Beta

This variation applies the HET trios to represent the sequence of events, and the Tripod
theory of incident causation, including “caused by” and “leads to“ guides, to establish
the latent failures. The Tripod Beta computer tool includes a number of wizards to
facilitate the several stages in building a Tripod tree. It also enables a report to be
generated in a standard format.
This method is described in detail in EP 95-0321 Tripod Beta, which is available on the
Exploration and Production web site at:
http://sww.siep.shell.com/hse/index.htm?target=/hse/safe/tripod.htm.
3.5.3 Other methods

The investigation and analysis of less serious incidents, where a Tripod analysis is not
being undertaken, should include an analysis of factors such as type of incident, type of
injury, phase of operation or activity, cause of incident. This type of analysis of all the
incidents occurring over a period of time can provide valuable input to an incident
prevention programme.
3.6 Incident Report and Follow up
3.6.1 Incident Report

The incident report presents the investigation findings, analysis and action plan.
Appendix 11 shows the recommended report format for an investigation of a significant

incident. If Tripod Beta is used for the analysis, the report can be generated automatically
in a standard format.
The incident report should be reviewed at the appropriate management level as a check
on the completeness and quality of the investigation and to obtain agreement to the
proposed actions.

Investigation
3.6.2 Legal advice

When compiling incident reports that may be required by authorities and other third
parties outside the company, it is recommended to seek legal advice before finalising the
reports. Requests for copies of incident reports should be considered individually taking
into consideration the potential risks and exposures for the company, its directors and
employees and the possibility of criminal or civil liability.
3.7 Communication of Lessons Learned
When the investigation of significant or high risk incidents reveals a significant learning
potential the lessons learned should be communicated within the business unit, and
where applicable, to the business. An incident is considered to have significant learning
potential when all the following criteria are met:
• The required controls are not standard industry practice or the incident involved a
combination of factors that are not commonly recognised;
• There has not been a previous communication in the past 3 years on the same
subject;
• The learning is widely applicable in the business or across industry.
Similarly, the business HSE adviser should decide if the lessons learned have value to
other Group businesses, and to industry in general. The learning should be
communicated through news forums, newsletters, cross industry working parties etc.
Additionally, when business HSE advisers receive the initial notification of a significant
incident, within 24 hours, they should consider the need to communicate the facts
known so far to the other business units in the same business and to other Group
businesses.

Introduction
Reporting of Incidents
4 REPORTING OF INCIDENTS
4.1 Reporting Company
The companies that are required to report incidents in accordance with this guide are
Shell companies and Joint Ventures that are under Shell’s operational control (JVs-uoc),
i.e. entities over which a Shell company has the full authority to impose the adoption
and implementation of the Group HSE Policy and Procedure.
For Joint Ventures not under operational control (JVs-nuoc), Shell companies are required
to use their influence to promote the Group HSE policy and to encourage JVs-nuoc to
report their HSE performance and incident data. Refer to Appendix 9 of Group HSE
Management System (1999) for details of the management of JVs-nuoc.
For shipping activities operational control applies to Group owned and demise (bare
boat) chartered vessels but excludes time or voyage chartered vessels. STASCO is only
operationally responsible for the STASCO managed fleet. The other fleets that are
included in the shipping sector, whilst reporting to STASCO, are the operational
responsibility of other operating companies, i.e. Shell UK, Norske Shell, Shell CAPSA,
ALSOC and SCOA.
The data included in the Shell Group external reports will draw on data reported by
Shell companies and JVs-uoc under this guidance and may be subjected to independent
verification.
When a company employee or contractor/consultant is visiting or on assignment in a

Group company other than his employing company the responsibility for reporting any
incidents associated with that employee lies with the employing company that also
records the employee’s exposure hours. The company being visited is responsible for
investigating the incident and for implementing resulting recommendations. This rule
also applies to employees of an internal consultant such as Shell International Health
Services or Shell Global Solutions International, despite the fact that these consultants
will have a contractual arrangement with the company being visited. The presumption is
that because they are Shell companies these consultants will be working to Shell Group
standards.
In the case that exposure hours are not calculated, e.g. for third party injuries and
environmental incidents, the company responsible for operating the equipment or
facilities involved is responsible for reporting.

Introduction
4.2 Reporting of Significant Incidents
All significant incidents, having actual consequences rated 4 or 5 on the RAM, shall be
notified to the business director within 24 hours. Final classification on the basis of the
investigation report is the responsibility of the business HSE adviser.
Refer to Appendix 13 for the details of the Procedure for Reporting and Review of
Significant Incidents.
Third Party Fatalities

All third party fatalities that are suspected to have resulted from work related activities,
shall be notified to the business, investigated and reported in line with the Procedure for
Reporting and Review of Significant Incidents in Appendix 13. Three types of third party
fatality are recognised:
A. If the investigation reveals that failures of company or contractor management
controls that should have been in place contributed to the incident causation, the
incident should be recorded in the company statistics.
B. If the investigation reveals that the incident was caused wholly by the action of the
third party, but some improvements are needed in company or contractor
management controls, the incident should be recorded in company statistics.
C. If the investigation reveals that the incident was caused wholly by the action of the
third party and all reasonable company and contractor management controls were in
place, the business unit can propose to the business HSE adviser not to record the
fatality in statistics.
All work related third party fatalities resulting from assault, sabotage and theft should be
included in the statistics.
Non-accidental Death
Non-accidental deaths involving company or contractor employees shall be notified to
the business within 24 hours, and investigated to:
• Decide whether there is a causal relationship between work and the death, in which
case the death should be classified as work related and recorded in statistics;
• Identify work related causes or contributing factors that may provide the grounds for
corrective action and improvement;
• Establish whether management systems were in place to ensure that fitness of
personnel was in line with requirements for the people’s job.
This also applies to non-accidental deaths outside normal working hours where there is
reason to suspect a relationship between the death and events or exposures at work.
The investigation should be conducted in a way that respects medical confidentiality,

particularly in the case of deaths outside normal working hours.

Introduction
The following questions need to be addressed:

• Were there any work related exposures, e.g. contacts with hazardous substances,
poor working environment, which could have contributed to the death?
• Were there any lifestyle factors e.g. diet, tobacco, alcohol abuse?
• Were there any pre-existing medical conditions?
• Has the individual been declared fit to carry out his normal duties in compliance
with company standards?
• Did the individual exhibit any signs or symptoms associated with the cause of death
before or during his recent work period?
• Was the individual recently referred to a doctor or hospital?
• Where death occurred on the company premises, were the company medical
emergency response procedures, including first aid, medical treatment and medieval,
suitable and complied with?
Examples:
Work related:
• Evidence that an individual has been exposed to high levels of a toxic chemical
during the course of his work;
• The individual had recently undergone major heart surgery and was not fit for work;
• The individual committed suicide and subsequent investigation showed that his
depression was mainly caused by work related stress factors.
Non-work related:
• Investigation has shown that an individual, who was previously found medically fit
for his duties, has died from the consequences of a heart attack.
Deliberate Death
Suicides and homicides should be notified to the business as soon as practicable. If the
initial investigation indicates a work-relationship they should be investigated in the same
way as an accidental death and included in statistics.

Introduction
Appendix 1: Definitions and Explanation of Terms

Asset Damage
A direct loss of or damage to plant, equipment, tools or materials resulting from an
incident. (Refer to guidance and examples in Appendix 6).
Business
One of the global Shell businesses, i.e. Exploration and Production, Oil Products, Gas
and Power, Chemicals, Renewables.
Business Unit
Activities in one of the Group businesses that are operated as a single economic entity. A
business unit can coincide with a Group company or straddle part or all of several
companies.
Consequential Business Loss

The indirect loss associated with incidents resulting in asset damage, environmental
impact or impact on company reputation. It comprises elements such as loss of
production (expressed as profit margin), process unit downtime, product quality costs,
cost of environmental clean up, cost of recovery/disposal of waste and cost of
reprocessing off-grade material.
The intention is to estimate the order of magnitude of the loss so that the incident can be
assessed on the RAM and the appropriate resources put into investigation. It should not
be necessary to conduct a detailed accounting of the full range of indirect costs.
Consequential business loss should be estimated on a 100% equity basis.
When consequential business loss results from an incident with impact on the
environment or company reputation, the consequences should be assessed under both
asset damage and the environmental/reputation categories of the RAM and the highest
rating used to determine the extent of investigation and follow up.
Company
Company or Group company means a Shell company, a Joint Venture under operational
control (JV-uoc), or a Joint Venture not under operational control (JV-nuoc) that has
agreed to report its HSE performance and incident data to Group following the reporting
methodology detailed in this guide.
Contractor
All parties working for the company either as direct contractors or as subcontractors.
Environmental Impact
The negative impact on the environment resulting from an incident. (Refer to guidance
and examples in Appendix 7).

Introduction
Exposure Hours
The total number of hours of employment including paid overtime and training but
excluding leave, sickness and unpaid overtime hours. Exposure hours should be
calculated separately for company and contractor personnel.
Time off duty, even if this time is spent on company premises, is not included in the
calculation of exposure hours, but incidents during this time are included in statistics if
they are the result of failure or absence of management controls. (Refer to guidance and
examples in Appendix 14).
In many company sites the number of exposure hours can be calculated from computer
controlled access or time keeping records. In the absence of more accurate methods
exposure hours can also be calculated from a headcount and nominal working hours per
person.
Fatality
A death resulting from a work related injury or occupational illness, regardless of the
time intervening between the incident causing the injury or exposure or causing illness
and the death.
Fires and Explosions

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

Any single treatment and subsequent observation of minor scratches, cuts, burns,
splinters, etc. that do not normally require medical care by a physician. Such treatment
and observation is considered first aid case even if provided by a physician or registered
professional personnel. (Refer to guidance in Appendix 3).
High Risk Incident (HRI)

An incident for which the combination of potential consequences and probability are
assessed to be in the high risk (red shaded) area of the RAM. HRIs can be incidents that
result in injuries, illnesses or damage to assets, the environment or company reputation,
or they can be near misses.
Incident
An unplanned event or chain of events that has, or could have, resulted in injury or
illness or damage to assets, the environment or company reputation.
Incidents do not include operations, maintenance, quality or reliability incidents which

had no HSE consequence or potential. Incidents do not include degradation or failure of
plant or equipment resulting solely from normal wear and tear.

Introduction
Injury
Any injury such as a cut, fracture, sprain, amputation etc. that results from a single
instantaneous exposure.
Lost Time Injuries (LTI)

The sum of injuries resulting in fatalities, permanent total disabilities and lost workday
cases, but excluding restricted work cases and medical treatment cases.
Lost Time Injury Frequency (LTIF)

The number of lost time injuries per million exposure hours.
Lost Workday Case (LWC)

Any work related injury that renders the injured person temporarily unable to perform
their normal work or restricted work on any day after the day on which the injury
occurred. Any day includes rest day, weekend day, scheduled holiday, public holiday or
subsequent day after ceasing employment.
This definition is different from the OSHA definition, which considers restricted work as
a lost workday case.
A single incident can give rise to several lost workday cases, depending on the number
of people injured as a result of that incident.
Lost Workdays (LWD)

The total number of calendar days on which the injured person was temporarily unable
to work as a result of a lost workday case.
In the case of a fatality or permanent total disability no lost workdays are recorded.
Medical Treatment Case (MTC)

Any work related injury that involves neither lost workdays or restricted workdays, but
which requires treatment by a physician or other medical specialist.
Medical treatment does not include first aid even if a physician or registered professional
personnel provide this. (Refer to guidance in Appendix 3).
Near Miss
An incident that could have caused illness, injury or damage to assets, the environment
or company reputation, or consequential business loss, but did not.
Occupational Illness
Any work related abnormal condition or disorder, other than one resulting from an injury
that is caused by or mainly caused by exposures at work. (50% or more probability that
the illness was caused by exposures at work).

Occupational illnesses include acute and chronic illness or diseases that may be caused
by inhalation, absorption, ingestion or direct contact. (Refer to guidance and examples in
Appendix 4).
Permanent Total Disability (PTD)

Any work related injury that permanently incapacitates an employee and results in
termination of employment.
Potential Incident
An unsafe practice or a hazardous situation that could result in an incident (incident has
not occurred).
Reputation Impact
The negative impact on company reputation resulting from an incident. The negative
impact can be in the form of adverse attention from media, politicians or action groups,
or in public concern about company activities. (Refer to guidance and examples in
Appendix 8).
Restricted Work Case (RWC)

Any work related injury which renders the injured person temporarily unable to perform
all, but still some, of their normal work on any day after the day on which the injury
occurred.
Restricted Workdays (RWD)

The total number of calendar days counting from the day of starting restricted work until
the person returns to his normal work.
When restricted workdays follow a period of lost workdays, the restricted workdays are
recorded in addition to the lost workdays, but the injury is recorded as a lost workday
case only.
Risk Assessment Matrix (RAM)

A tool that standardises qualitative risk assessment and facilitates the categorisation of
risk from threats to people, assets, environment and company reputation. The tool is
described in detail in the HSE Adviser’s Panel guide Risk Assessment Matrix (1999).
Road Transport Incident

An incident involving a vehicle driven by a company or contractor employee, whether
on or off the road, that has resulted in injury, illness or damage to assets, the
environment or the company’s reputation, irrespective of the cost of repair or
responsibility for cause.
A vehicle is defined as a car, van, light vehicle, heavy goods vehicle, road tanker, bus,
motorcycle or any unit under tow, e.g. trailers, caravans, mobile generators.

This definition does not include:

• Incidents involving vehicles operating on aprons of public airfields;
• Damage as a result of normal wear and tear, e.g. minor paint scratches, stone chips,
and mechanical wear and tear;
• Incidents which occur when the vehicle was unattended, e.g. vandalism or other
damage whilst the vehicle was parked. These would be considered as incidents rather
than transport incidents.
Significant Incidents
Incidents with actual consequences to the company that rate 4 or 5 on the RAM.
Third Parties
Persons or organisations that are not employed by or contracted to a company or
contractor.
Total Sickness Absence

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

The sum of injuries resulting in fatalities, permanent total disabilities, lost workday cases,
restricted work cases and medical treatment cases.
Total Reportable Case Frequency (TRCF)

The number of total reportable cases per million exposure hours.
Total Reportable Occupational Illness (TROI)

The sum of all identified occupational illnesses. Cases involving no lost or restricted
workdays and no medical treatment are included. A single exposure can give rise to
several occupational illness cases.
Total Reportable Occupational Illness Frequency (TROIF)

The number of occupational illnesses per million exposure hours.
Vehicle Kilometres Driven

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

Those activities for which management controls are, or should have been, in place. Refer
to Section 2.1 for detailed guidance. Injuries occurring in the course of work related
activities are work related injuries.

Appendix 2: Incident Classification and Reporting
Flow Chart
Appendix 2: Incident Classification and Reporting

Flow Chart
Incident occurs
N Actual loss? Y
Work N
Near miss Related? Not reportable
N Injury/
illness?
Asset, Y
N High risk environment
on RAM? or reputation
incident
Y
Fatality N
or PDT?
Y Illness? N
N Learning
for others?
Lost
Y N
Workdays?
Y
Y Restricted N
work?
N Consequence
4 or 5? Y Medical N
treatment?
Y
Y
TROI LWC RWC MTC FAC
Report Voluntary Immediate Routine reporting to Business Report

within reporting notification within
Company to to Business Company
Business

Appendix 3: 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 burns;
• Application of sutures (stitches);
• Application of butterfly adhesive dressings or steri strips in lieu of sutures;
• Removal of foreign bodies embedded in eye;
• Removal of foreign bodies from wounds, 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 compresses 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 of fractures, broken bones, etc.;
• Admission to a hospital or equivalent medical facility for treatment or observation;
• Loss of consciousness, even if no treatment was given. 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 burns;
• Application of bandages during any visit to medical personnel;
• Use of elastic bandages 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,
e.g. 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 compresses 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 or laboratory analysis, unless they lead to further treatment;
• Observation of injury during a visit to medical personnel;
• Administration of tetanus shots or boosters. These shots are often given in
conjunction with more serious injuries, therefore, injuries requiring these shots may
be included in the statistics for other reasons.

Appendix 4: Distinguishing between Injuries and Illnesses,
and Determining whether Illnesses are
Occupational

Occupational
Occupational illness is any abnormal condition or disorder, other than one resulting from
an injury that is caused by or mainly caused by exposures at work. (50% or more
probability that the illness was caused by exposures at work).
Occupational illnesses include acute and chronic illness or diseases that may be caused
by inhalation, absorption, ingestion or direct contact.
Whether a case involves a work related injury or an occupational illness is determined

by the nature of the original event or exposure that 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 to be occupational illnesses.
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 by, 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 affected employee exposed to these agents in the work environment?
• Was the exposure to a sufficient degree and duration to result in the illness
condition?
• Was the illness attributable mainly to a non-occupational exposure?
The material safety data sheets for those substances suspected of causing employee
illnesses should be checked to verify the relationship between the exposure and the
resulting symptoms.
Musculo-skeletal Conditions including Back Problems
A medical condition involving the musculo-skeletal system may be a work related injury,
an occupational illness, or a non-work related injury or illness.
Work Related Injury Guidance

A musculo-skeletal problem is considered to be a work related injury if the affected
person was engaged in a work related activity and there is a clear record of an incident,
i.e. an identifiable unplanned event, such as a sudden effort or over exertion, blow to the
back, slip, trip, or fall. Generally the employee reports sharp and sudden pain during or
shortly after the event. The pain may come and go over a period of time or may not
become a significant problem for 24-48 hours after the activity.

Occupational
Examples
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. The worker caught it and forced it into
place, but in doing so felt a sharp pain in the back. This would be considered work
related injury, since the condition resulted from the sudden effort required to prevent
the unit from falling.
2. A worker’s foot slipped in the process of swinging a hammer and a back pain
developed immediately. This would be considered a work related injury, since the
onset of symptoms was directly associated with the slip that occurred in the course of
and arose out of employment.
3. An employee with a known back problem experienced a recurrence of back pain
whilst lifting a drum of lubricating oil. This would only be considered a work related
injury if the original condition was aggravated as a consequence of a lifting action
which was outside the normal limits of the task, i.e. over exertion.
4. A clerk who is usually involved in work that is not physically demanding was asked to
assist in unloading a large shipment of heavy items by hand. The clerk felt no
discomfort that day but the following morning the his right shoulder and back muscles
are so sore that he was unable to perform the normal job effectively and had 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.
Occupational Illness Guidance

A musculo-skeletal problem is considered to be an occupational illness if it is caused by
prolonged or continued exposure to over exertion in the performance of the employee’s
duties. The recurrence of symptoms from previous cases need not be reported as a
separate occupational illness unless they have recurred as a result of new exposures that
differ from the original exposure.
Examples
1. An employee reported severe back pain that 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 over exertion in the performance of the
employee’s duties. The case would be considered an occupational illness.
2. A seismologist was engaged routinely in the use of a standard mouse in manipulation
of on-screen data. Over a period of some weeks he noted gradual onset of pain,
stiffness and local tenderness over the wrist and forearm that improved following a
break from work. After clinical assessment of the case, it was concluded that the
condition primarily resulted from continuous over exertion and would be considered
an occupational illness.
Non Work Related Injuries and Illnesses Guidance

A musculo-skeletal problem would not be considered to be a work related injury or an
occupational illness if the condition merely surfaced at work spontaneously and without
provocation from an external force, work activity or an incident in the workplace, but
arose solely out of a pre-existing condition.

Occupational
Note: A pre-existing condition does not affect the reportability of a subsequently
contracted work related injury or occupational illness. If an injury or illness is caused or
mainly caused by exposures at work it must be reported without regard to the
employee’s pre-existing condition.
Examples
1. An employee sprained lower back muscles in a minor road traffic accident whilst on
leave. The pain eased and the employee was able to return to work a few days later.
A recurrence of the pain was felt when the employee got up from his chair. There is
no evidence of a prior incident at work causing or contributing to the condition. This
condition is attributed solely to the employee’s pre-existing physical condition and
therefore would not be considered a work related injury.
2. An employee reached up without overreaching to pick up a hard hat from the top of
a locker and experienced back pain. There was no evidence of a prior incident, the
trigger for the condition was within normal job limits, the employee had no previous
history of work related back problems, and therefore the condition would not be
considered as work related.
3. Conditions occurring spontaneously at work without provocation from an external
force or work activity, e.g.:
• An employee turns his or her head to answer a question or gets up from a chair
and experiences sudden pain onset;
• An employee kneels to tie his or her shoelaces and experiences back pain;
• An employee coughs and complains that his or her back has “gone”.
• These events would not be considered as work related.
Repetitive Strain Injury (RSI)
RSI is a medical syndrome caused by repetitive movements affecting the neck, upper
back, shoulders, upper and lower arm, elbow, wrist or hand, or a combination of these
areas. It is considered to be RSI if the effects are restrictive or lead to participation
problems.
RSI is sometimes referred to as Cumulative Trauma Disorder (CTD), Occupational

Cervico brachial Disease (OCD), Occupational Overuse Syndrome (OOS) and others.
RSI is always caused by a combination of factors. These include excessive use of force,
working in awkward positions, working continuously in the same position and repeated
and continued movements. For further guidance refer to the HSE Advisers’ Panel guide,
RSI in the Office Environment (2001).
When an RSI is classified as an occupational illness, it is classified as per Appendix 5 as

a musculo-skeletal disorder of the upper limbs.

Occupational
Work Related Stress
A stress case is considered to be work related when there is an identifiable organisational

and/or interpersonal factor in relation to work and the working environment which has
contributed to a stress related disorder requiring significant intervention, such as specific
counselling or treatment, modification of duties or loss of time from work.
Stress reactions caused by traumatic events at work, such as being involved in an armed
robbery, a major explosion or fire in the work environment, are also considered to be
work related.
Burns
Contact with heat, electricity, intense radiation or a caustic chemical that produces a
burn in a single contact, is a work related injury. Sunburn or welding flash burns that
result from prolonged or repeated exposure are considered occupational illnesses.
First degree burns are classified as first aid cases. Second degree burns are normally
classified as medical treatment cases. Third degree burns are always classified as medical
treatment cases.
First Degree Burns

Only the outer layer of skin is damaged, characterised by reddening of skin, pain and
sometimes swelling. It is not reportable if the condition doesn’t require repeated
treatment beyond initial antiseptic. When a blister forms three days after the burn occurs,
a first degree burn should be upgraded to a second degree burn.
Second Degree Burns

Injury to the epidermis and damage to the superficial underlying tissues. The injury is
characterised in similar way to first degree burns but blistering of skin may also occur.
Intense pain, reddening and a mottled skin appearance are common.
These cases are reportable if:

• Medical treatment is required beyond initial antiseptic;
• Blistering is larger than one inch in diameter;
• Damage is not considered “minor” by a medical professional.
An injury is not “minor” if it:

• Must be treated by a physician;
• Impairs normal use of limbs or senses;
• Results in damage to the physical structure beyond a non-superficial nature;
• Requires follow up medical treatment.
Third Degree Burns:

Most serious category of burns where the entire skin thickness is affected, with
blackened or blanched grey-white skin. Treatment includes debridement (removal of
burned skin) and skin grafts. All work related cases are reportable.

Occupational
Dermatitis
Example:
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
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.
Animal Bites and Insect Stings
Animal bites and insect stings are normally considered as work related injuries if they
occur in the course of employment. However, repeated exposure may result in disorders
that are considered occupational illnesses.
Example 1:
A snake bit a lineman engaged in routine work. The case would be considered a work
related injury.
Example 2:
Insects carrying the disease leishmaniasis bit a member of a party clearing jungle for
seismic work. The resulting sickness would be considered an occupational illness.
Example 3:
Malaria or other diseases that result from mosquito bites or insect stings are classified as
occupational illnesses.
Heart Attacks
Heart attacks are not normally classified as work related injuries because they normally
do not result from single instantaneous incidents in the work environment. When heart
attacks do occur, they should be assessed against the criteria for occupational illnesses.
This means that heart attacks occurring in the working environment should only be
classified as occupational illnesses if they result or mainly result from exposures at work.

Occupational
Infectious Diseases
Infectious diseases such as malaria and Chagas disease are only reportable if they have
been confirmed by clinical testing or by a doctor. If the illness is endemic to an area or
the country and employees indigenous to that area are diagnosed with the illness on a
regular basis cases should not be reported. If the illness occurs among employees from
an area where the illness is not endemic, the illness should be classified as an
occupational illness.
Common Subjective Symptoms
Complaints of such common subjective symptoms as general malaise, headache, nausea,

are not occupational if they are not caused or mainly caused by exposures at work. 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. One should pay attention to the
distribution of such subjective complaints in time and place, particularly when such
complaints are observed to occur among one or more groups of employees.
Food Poisoning
Food poisoning cases arising from food furnished by the employer on the employer’s
premises should be reported as occupational illnesses. This is an exception to the general
rule that single incidents are considered as injuries.
Noise Induced Hearing Loss
Noise induced hearing loss should be classified solely on the criteria contained in the
SHC Noise Guide (1991).
Eye Problems
Example:
An employee goes to a doctor and is informed that she should wear prescription glasses
because of work related eye deterioration caused by the nature of the job. If it can be
established that the disorder was caused or mainly caused by exposures at work this case
would be classified as an occupational illness. However, the company should distinguish
work related eye problems from those due to ageing or hereditary factors unrelated to
the job.

Occupational
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 should 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, but declared fit for duty, suffered a recurrence
of the disability whilst 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.
Pre-existing Conditions
An employee’s physical or mental defect or pre-existing physical or mental condition

does not affect the classification of a subsequently contracted occupational illness. If in
such circumstances an illness is caused or mainly caused by exposures at work, the
company must report it without regard to the employee’s pre-existing physical or mental
condition.
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.
Reaction to Medical Treatment
The classification of a disorder resulting from medical treatment depends upon whether
the treatment was for work related purposes.

Occupational
Example:
An employee going on a business visit was vaccinated against yellow fever. Some days
later the employee was taken ill and the illness was linked to the vaccination. This would
be considered an occupational illness.
Recurrence of Symptoms
Companies are required to report each new occupational illness. The recurrence of
symptoms from a previous case 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
that recur over time. The recurrence of these symptoms should not be reported as a new
case, unless the occupational illness results in an escalation of severity, e.g. to death 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. They should be
reported as new cases.
Medical Verification by a Medically Qualified Person
Medical verification is encouraged but not required for classification. 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.
Individual Susceptibility
Variations in the characteristics of particular employees of their susceptibility to various

illnesses should not affect the classification of an injury or illness.
Permanent or Temporary Transfers
Permanent or temporary transfers to another job to remove employees from further

exposure to health hazards are preventive in nature. If no occupational illness has
occurred they are not considered reportable events.

Occupational
Overexposure to Health Hazards
Exposure of workers to hazardous chemicals at concentrations above the Occupational

Exposure Limit (OEL), or to other health hazards above their respective control limits,
should be considered as incidents. When the overexposure do not result in occupational
illnesses they should be considered as either near misses or potential incidents,
depending on whether incidents actually occurred.
Examples of exposures are:

• Working in a noisy area without hearing protection or other measures to reduce
noise levels;
• Inhalation of a toxic chemical following a spillage without taking precautions;
• Working with hazardous materials such as asbestos containing products without
taking precautions;
• High results from routine exposure measurement;
• High legionella count in water systems that could generate an aerosol and be
inhaled.

Appendix 5: Classification of Occupational Illness

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, sensitisers or
poisonous plants, oil acne or chrome ulcers.
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 benzene, epichlorhydrin and
formaldehyde.
Upper limb and neck disorders:

synovitis, tenosynovitis, and bursitis; Raynaud’s phenomenon; other disorders of the
musculo-skeletal system and connective tissue associated with repeated trauma,
including RSI.
Back problems and lower limb disorders:

synovitis, tenosynovitis, and bursitis; Raynaud’s phenomenon; other disorders of the
musculo-skeletal system and connective tissue associated with repeated trauma,
including chronic back disorders caused by exposures at work.
Cancers and malignant blood diseases:

mesothelioma; bladder cancer; leukaemia and other malignant diseases of blood and
blood forming organs.
Disorders due to mental stress:

depression, neurosis, stress, functional disorders of the gastrointestinal tract and recurring
tension headaches.
Noise induced hearing loss:

definition and criteria for reporting are given in the SHC Noise Guide 1991.

Other Illnesses and disorders:

Physical disorders such as heatstroke, 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).
This category also includes benign tumours; eye conditions due to dust and toxic agents;
other (non-malignant) diseases of blood and blood-forming organs.

Appendix 6: Asset Damage - Examples
Appendix 6: Asset Damage - Examples

Asset damage is a direct loss of, or damage to, plant, equipment, tools or materials
resulting from an incident. The consequences of the incident may include both direct
loss or damage or consequential business loss. The consequences should be assessed on
the RAM.
Example 1
Whilst a crane was lifting a heat exchanger on a crude oil production module, it was
dropped onto an instrument airline that ruptured. Instrument air supply was lost and the
module was shutdown safely without further damage or leakage. It took 6 hours to repair
the instrument airline and a further 6 hours to re-commission the module and re-
establish crude oil production.
As the event posed a threat to people in the vicinity and the instrument air loss could
have led to further plant emergencies this event would be considered an (HSE) incident.
The asset damage resulting from this incident was the cost of repairing or replacing the
instrument airline. The consequential business loss was the cost of lost crude oil
production. In assessing the cost of lost production no account should be taken of the
possibility of making up the lost production using spare capacity in the production
programme. The cost should be based on the design or programmed capacity of the
module and the downtime.
If the falling heat exchanger had been damaged its repair or replacement cost would be
included in the asset damage. If the repair or replacement of the heat exchanger caused
delays in achieving improved throughput, heat saving or product quality the associated
costs would be included in the consequential business loss.
Example 2
A gasoline process pump was allowed to run dry, the pump vibrated and the bearing
failed. The seal held and there was no leakage of gasoline.
This event resulted in damage to the assets but there was no harm to people, the
environment or company reputation. The event would not be classified as an (HSE)
incident. However, it might be reported as an operational disturbance, a maintenance
item or a quality incident.

Appendix 7: Environmental Impact - Examples

Environmental impact is the negative impact on the environment resulting from an
incident. This section illustrates with examples the main types of environmental impact.
Note that many of the examples also have an impact on company reputation.
Atmospheric Emissions
Example 1: Emission of hydrogen sulphide

A refinery sour water pump seal failed and released hydrogen sulphide into the plant
area, triggering the toxic gas detection and alarm system. The pump was quickly
switched off 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.
Although the assessment revealed that there were unlikely to be off-site complaints, there
was a potential safety problem on-site, therefore the incident should be considered as a
near miss and investigated.
Example 2: Emission of hydrogen sulphide from a flare stack

The refinery flare extinguished whilst waste gas containing hydrogen sulphide was being
flared. There was a rotten eggs smell in the neighbouring village 1 km away that led to a
number of complaints being made by residents.
As hydrogen sulphide went offsite in concentrations above the odour threshold, and
resulted in complaints, this should be considered as an incident with environmental and
reputation impact.
Example 3: Halocarbons
All accidental releases of halocarbons, i.e. CFCs and halon, should be considered as
incidents regardless of size of emission.
Oil and Chemical Spills
When a spill is not contained within the site or within the process system it should be
considered as an incident having environmental impact.
Example 1: Fuel oil spill during work on pipeline

A large diameter fuel oil pipeline in the tankage area of a refinery was being opened up
for maintenance. Because the line had not been adequately cleaned 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 river.

As the spill was contained within the site, and did not pose a risk to groundwater
systems because it was contained within impervious drainage channels, it was not
considered an incident with environmental impact. However, it should be reported as a
near miss and investigated to prevent recurrence.
If the same spill occurred under conditions of high rainfall and some of the oil was
discharged through the outfall and recovered from the river (controlled water), then the
spill clearly had an environmental impact. If the incident was serious enough to draw the
attention of the environmental authorities and the media, the impact on company
reputation should also be taken into account.
The cost of lost fuel oil and the cost of clearing up and disposing of the oily water are
consequential business loss that should be assessed against the asset damage criteria on
the RAM.
Example 2: 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. Approximately 200 litres went into the harbour. The vessel’s 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 incident with environmental impact. The fact that the Authorities
were involved, and the incident attracted local media attention, means that it should also
be considered as an incident with reputation impact. The incident should be classified
and reported on basis of the highest RAM rating.
Complaints
Example 1: 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 that was faulty. Even though there were no prescribed
maximum noise limits in the local community, the complaint should be considered as an
incident.
Example 2: Smoky flare

A call was received from the pollution inspector that a member of the public had
complained that the 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. This
would be considered as an incident with impact on company reputation.

Non-compliances
Example 1: Disposal of waste paint tins

Three partly full 5 litre tins of liquid paint were found in a general waste skip that 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 as an incident. As there
had been previous non-compliances on that landfill location which had come to the
attention of the local press, the impact on reputation should also be taken into account.
Example 2: Construction waste

A LNG plant was being constructed on a green-field site. The conditions of the permit for
construction and operation of the plant specified that disposal of hazardous waste should
be reported to the environmental authority. Oil and chemical waste was found in the
local landfill site and was traced back to unauthorised tipping by the construction
contractor.
This was a clear non-compliance with the permit conditions and should be reported as
an incident.

Appendix 8: Reputation Impact - Examples
Appendix 8: Reputation Impact - Examples

Reputation impact is the negative impact on company reputation resulting from an
incident. The negative impact can be in the form of adverse attention from media,
politicians or action groups, or in public concern about company activities.
The consequences of reputation incidents should be assessed using the RAM taking into
account the specific local circumstances and sensitivities.
A number of the environmental examples in Appendix 7 also demonstrate how various

types of incident can damage company reputation.
Further examples of incidents inside and outside Shell that damaged the company’s
reputation can be found in the Group crisis management web-site at:
http://sww.shell.com/crisismanagement/.

Appendix 9: Incident Investigation Guidance

This appendix provides a checklist of subjects to be addressed during the investigation of
incidents.
Conducting Interviews
Interviews with witnesses should be carried out as soon as possible after the incident, as
intervening time and discussions with others can influence a person’s recollection of
events. The value of a witness’s input 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 it by
making comments or asking leading questions. This requires patience and understanding.
An investigation team is often seen in a prosecuting role, and witnesses may be reluctant
to talk freely if they think they may incriminate themselves or their colleagues. An
investigator is not in a position to give immunity in return for information, but must try to
convince interviewees of the purpose of the investigation and the need for frankness. The
following are some points of good practice when conducting an interview:
• Prepare the questions you need answered beforehand;
• Avoid interviews by the whole investigation team that may intimidate the witness.
The optimum is two interviewers and a single witness. Also avoid interviews by
immediate supervisors;
• Allow the witness to be accompanied by a colleague or friend or a safety
representative;
• Conduct the interview in private and start off with a general discussion to put the
witness at ease before asking questions about the incident;
• Make sure that the witness understands that he or she will not be required to sign a
statement;
• Ask the witness to go step by step through the events surrounding the incident,
describing both own actions and the actions of others. Do not ask leading questions;
• Separate facts from opinions. Ask further questions to confirm the facts, and note the
opinions;
• Summarise the discussion at the end of the interview to make sure that there is no
misunderstanding. Afterwards, prepare notes of the discussion and agree them with
the witness. Clarify any anomalies and any conflicts with other evidence;
• Assess the need for the witness to receive counselling.
Inspecting the Location
Important facts and data can be gained from observations made at the scene of the
incident, particularly if the location is kept undisturbed until the preliminary
investigation has taken place. Rescue operations or the presence of residual hazards may
necessitate moving some of the equipment, but this should be kept to a minimum.
Before disturbing the incident location photographs and/or video film should be taken.

Sketches can be used to document the physical relationship and distance between
people, tools and equipment. All relevant equipment, tools, clothing, PPE and other
material evidence should be identified and labelled. If critical equipment or tools have
been damaged or have failed they should be kept in a secure place pending more
detailed analysis.
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.
Investigators should look for any conditions or factors at the location that could have
contributed to the incident. Factors to check include:
• Position of all equipment in relation to other equipment and people;
• Position of valves, spades, set points, recorders, override switches, etc.;
• Samples of process materials, products of reaction/combustion, drain water etc.;
• Process control and safeguarding instrument status. Check that records are retained
beyond 24 hours;
• Procedures, vehicle tachographs, training records, log books, process logs and test
records;
• Condition of the load-bearing surface;
• Accessibility and evidence of congestion;
• Lighting, visibility and audibility at the location;
• State of housekeeping;
• Condition of all plant, vehicles, equipment and tools;
• Effects of weather;
• Presence of witnesses;
• Evidence of spills or release;
• Odours, discoloration, tyre marks;
• Presence of unauthorised people;
• Evidence of excessive forces;
• Presence of warning signs and notices.
Collecting Background Information
Background information will include:

• Process design and operating manuals;
• Procedures for the type of operation involved;
• Records of instructions and briefings given on the particular job being investigated;
• Location plans;
• Organisation and persons involved;
• Product information and MSDS.

Fact Finding
During the initial stages of every investigation, investigators should collect and record all
the facts that may add to the understanding of the incident and the events surrounding it.
They should be aware of the danger of reaching conclusions too early and of failing to
keep an open mind to the full range of possibilities. They should ask the questions who?,
what?, when?, where?, why? and how? about the circumstances of the incident. Here is a
checklist of specific questions that should be answered during the fact-finding process:
• What operations were in progress?
• What equipment was in use? Had any of the equipment failed?
• Where were the key personnel and what were their actions immediately before the
incident?
• What instructions were given that are related to the incident?
• What energy sources and flows were not controlled?
• Were there any operational deviations, equipment defects or inappropriate use of
resources and equipment?
• Were there any changes of personnel, procedures, processes or equipment that could
have contributed to the incident?
• What were the weather conditions?
• What action did any third parties take that contributed to the incident?
• Were the individuals involved physically fit and competent to perform the job?
• Could alcohol or drugs have been a contributory factor? Should tests be done?
• Could the effect of fatigue, work cycles and stress be contributory factors?
• Could social or domestic pressure have had an impact on an individual’s behaviour?
• Could time of day, age of people involved, length of service, training received etc. be
contributory factors?
After a first round of fact finding it should be possible to give a precise description,
supported by the documented facts, of the events leading to the incident, the incident
itself and the initial response to the incident. It should be possible to:
• Describe the consequences of the incident in terms of injury, damage and loss,
environmental and reputation impact;
• Identify what defences (controls and recovery measures) were in place to prevent the
incident;
• Identify the substandard acts which breached these defences;
• Identify the preconditions which led to the substandard acts;
• Identify what additional information and specialist resources are needed to confirm
the immediate causes and to establish the underlying causes (Tripod latent failures);
• Comment on response to the incident, including first aid, emergency medical
treatment, rescue, shutdown of the process and fire fighting.

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

records, printouts, log sheets/books, maintenance records, work permits and load/time
sheets may provide information relevant to the investigation.
Written instructions and procedures may 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 this can indicate
the effectiveness of training and supervision. The relevance and extent of application of
procedures should be assessed during the investigation.
Special Studies
Incidents of a technical or complex nature often require specialist input and further
studies to determine causes of failure. Aircraft crashes, crane failures and plant
explosions are examples of such incidents, where specialist advice may be required. This
should be rapidly identified and the specialists involved early in the site assessment.
Conflicting Evidence
It is not unusual for witnesses to give differing accounts of an incident. Human memory
can be unreliable and, even if not motivated by self-protection or other subjective
arguments, one person’s recollection of an incident can differ from another person’s in
important details. Investigators should note any significant differences in accounts of an
event. Faced with conflicting witness 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.

Time
Appendix 10: Sequentially Timed Event Plot - Example
Appendix 10: Sequentially Timed Event Plot - Example

Actor 28/5 7/6 7/6 pm 10/6 13/6 am 14/6
P9101 A On-line
Minor Seal repair Seal repair Reinstalled

P9101 B On-line
leak on priority 3 delayed & started
Hot & noisy Bearing Tripped,

Reinstalled
P9101 C On-line Taken re-sleeved bearing
& started
of-line incorrectly seized
Electrical Young &

technician inexperienced
Rotating
Did not
equipment
advise
section
Not
Plant
informed
manager
of problem
Boiler
Reduced
feed water
flow
flow
41
Appendix 11: Incident Report Layout for a
Significant Incident

This appendix lists the headings and provides guidance on the content of a report of a
significant incident. When the Tripod Beta tool is used to analyse the incident the report
can be generated automatically from the data inputted to the Beta Tool software.
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 causes established
and the agreed actions.
Place, time and date of incident
Consequences
Details of persons injured, and the injuries in a form understandable to non-medical
readers.
Description of the damage and loss, including an estimate of the cost of direct and
consequential losses.
Events leading up to the incident

A short narrative that sets the scene of the incident:
• Description of the operation in progress;
• Preparations made for the work, including work procedures, instructions, permits and
supervision;
• Personnel involved including work and shift patterns;
• Equipment involved;
• Environmental and weather 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.
Description of the Incident

A statement of the facts immediately surrounding the incident, covering the period from
the initiating events until the situation was under control. The statement should include
photographs, drawings or maps to illustrate the narrative. It should also include a
presentation of the sequence of events, using one of the methods described in Section
3.4 of this document.

Results of the investigation

This section should demonstrate that the investigation was carried out in sufficient depth
to support the conclusions that follow. Where relevant, it should include references to:
• Environmental conditions;
• Condition of equipment and facilities, including inspection and maintenance history,
operating mode;
• Procedures relating to the operation;
• Information about the training and experience of persons involved;
• Work instructions and communications;
• Records and documentation;
• Information derived from the nature of the damage;
• Witness statements;
• Medical records;
• 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.
Results of analysis
This section should include the results of the analysis of the findings, identifying the
immediate and underlying causes and weaknesses in the management system. The
results are normally presented as a Tripod tree.
When certain conclusions have not been fully established by the available evidence
these should be highlighted as tentative conclusions.
Action items
This section should include corrective actions for immediate causes (Tripod breached
defences) and improvement actions addressing the underlying causes and management
system weaknesses(Tripod latent failures). Action items should be achievable and
measurable, and should specify action parties and implementation times.
Appendices
Sequence of events.
Tripod tree and GFTs.
Other data needed to supplement the report, including photographs, and drawings.

Appendix 12: Work Related Activities -
Guidance and Examples

Transportation of Personnel
a) Work Related
• Personnel travelling on company business using public or private transport from their
normal place of residence or regular place of work to a temporary place of work;
• Personnel travelling in company owned or arranged transport;
• Personnel travelling from temporary accommodation, e.g. base camp or hotel, to a
place of work.
b) Not Work Related

• Company and contractor personnel commuting between home and normal work
place not using company arranged transport;
• Non-business related travel in vehicles that are allocated to employees or contractor
personnel for their unrestricted personal use;
• Company and contractor personnel commuting in own or public transport from their
home to an assembly point where they are collected in transport provided by their
employer;
• Personnel deviating from a business trip for personal reasons provided this does not
breach company procedures.
Example 1:
An employee on a business trip travelled by taxi from an airport to the hotel where he
would stay. He was injured in a road incident during the taxi journey. The injury is work
related.
Example 2:
An employee, who has a company vehicle for unrestricted personal use, was due to
attend a business meeting some distance away on a Monday morning. He decides to
leave on the Friday and break the journey by visiting friends. An incident occurred
during the diversion from the normal route. The resultant injury is not work related.
Example 3:
A ship’s crewmember was travelling ashore by launch for an authorised recreational trip.
He was expected to arrange safe transport. An incident occurred when the launch
collided with another ship and the crewmember was injured. The injury is work related.
When an incident occurs during travel in non company arranged transport and
subsequent investigation shows that company transport should have been provided, for
example if incidents during this activity could create a negative impact on the company,
then the incident should be considered work related.

Example 4:
An employee had to travel from home to the local airport for a weekly shift at a location
upcountry. The roads were known to be dangerous because of frequent armed robberies.
If no company transport was provided then a robbery involving an employee in private
transport would be considered work related.
Working from Home
When an employee is involved in a formal company sponsored program for working at

home, injuries or illnesses that occur while performing duties for the employer while at
home would be work related. An employee with his or her home as an office is
considered to be at work when in that office or when leaving this office on company
business. If an employee who works from home is injured or becomes ill while
performing normal life activities, e.g. eating, the case would not be work related.
Working Away From Home
When an employee is travelling on company business the total period away from regular
place of work, including normal life activities, e.g. in a hotel and travelling by taxi to a
meeting, are considered to be part of employment. Any injury or illness occurring during
the business trip is considered to be work related.
Company or contractor employees may be required to live on board tankers, fixed or

floating platforms, supply vessels, standby boats, construction workers camps or other
accommodation provided by the employer as part of their normal work assignment.
Injuries occurring during normal life activities are assumed to result from the employee’s
presence at the location, as required by the company or contractor, and therefore to be
work related. If investigation of an incident reveals that it was caused wholly by the
action of the employee and failures of management controls did not contribute, the
incident is not work related.
In case of illnesses that materialise during business travel the normal criterion for
occupational illness should be applied, i.e. was the illness caused by or mainly caused
by exposures in the workplace?
Example 1:
An employee sustained an injury in an offshore gymnasium during off duty time. If
management controls were not breached the injury is not work related. If the injury
resulted from a failure of one of the pieces of equipment it would be work related.
Example 2:
An outbreak of food poisoning occurred in a contractor’s construction workers’ camp. As
the outbreak clearly resulted from a failure in hygiene standards of food provided by the
contractor the illnesses would be occupational.

Transportation of Goods and Equipment
Considered to be Work Related

• Transportation of goods and equipment within company managed locations;
• Transportation of goods and equipment on company owned or contracted transport,
including subcontractors and spot hire transport;
• Transportation of goods and equipment that is readily identifiable as related to the
company operations, e.g. seismic vehicles and land drilling rigs, or process
equipment for a new plant construction.
Not considered to be Work Related

• Transport activities which are not dedicated to the supply of goods and equipment for
the company or its contractors that are not readily identifiable as related to company
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 involving company or contractors’ employees on company premises or
working under the company’s management control.
Example 1:
A road haulier was working under a term contract to deliver product on the company’s
behalf. The haulier worked for a number of other companies. An incident occurred
during the time the haulier was delivering product exclusively for the company. The
injury should be included in the company statistics, as should the associated exposure
hours and the kilometres driven.
• All incidents occurring within company managed locations or alongside company
managed pipelines.
• Incidents which occur when company or contractor vehicles, including sub
contractor or spot-hire vehicles, are undertaking the following journeys, whilst
subject to company management control:
• a terminal or depot to load products;
• From a terminal or depot to deliver products to a customer;
• From a customer to a terminal or depot or to a contractor base or other predefined
base, to complete the journey;
• To or from a workshop or garage for vehicle service or maintenance.
• Incidents occurring in vehicle parking areas or other off-road situations, e.g. customer
premises, whilst subject to company management control.

Not considered to be Work Related

• Incidents to contractors not subject to company management control, for example:
• Delivery of products to company locations by a contractor who is also employed
by other companies to deliver their products to other locations during the same
journey. However, when such vehicles are within the company location both the
vehicle and driver must comply with the company standards and requirements,
and the activities will be considered as under operational control;
• Customer collection of company products where the vehicle is under the
management control of the customer, e.g. freight on board sales of products to
dealers or distributors not under operational control ex-depot. As in the previous
example the vehicle is considered to be under operational control when at the
company location;
• Back-haul journeys where the contractor vehicle carries products for other
companies or has been re-routed by the contractor on behalf of another company,
or for his own benefit;
• Contractor assigned by a local authority to an activity when the company is unable
to impose management control.
Injuries during Training
Example:
An employee attended a course at a training school and sustained an injury. As the injury
occurred during the training sessions it is a work related injury. Had the injury occurred
in the employee’s recreational time, and was not caused by a failure of management
controls of the training centre, it would not be work related.
The injury and the exposure hours should be included in the statistics of the company
employing the injured person. The training centre should investigate and follow up the
incident and report the findings to the employing company.
Meal Period Illnesses
Illness caused or mainly caused by exposures occurring during the employee’s meal
period or other off duty periods are not considered as occupational unless they result
from exposures to hazards in the work area.
Example 1:
An employee suffered food poisoning resulting from food provided by the employer. This
case would be considered an occupational illness.
Example 2:
An employee was sitting in the canteen and eating food that he had brought to work. He
suffered food poisoning. The case would not be considered an occupational illness.

Fitness Centre
Incidents involving employees at company physical fitness centres are not normally work
related, even though the company encourages participation in fitness programs and
subsidises the costs of participation. If participation is required as part of employment,
then any resulting incidents are work related. If an injury results from a failure of one of
the pieces of equipment or other management controls it would be work related.
Entertainment of or by Customer, Supplier or other Business Contacts
An injury or illness caused or mainly caused by exposures which occur while an

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 a work
related injury or an occupational illness.
Recreation and Social Events
Company premises include all employer controlled sports fields, tennis courts, golf
courses, parks, swimming pools, gyms, social clubs and other similar recreational
facilities which are used by employees on a voluntary basis primarily during off-work
hours. The Company should maintain management controls appropriate to the facilities,
activities and participants. Injuries to employees, their families or others are considered
to be work related if they result from failures in the management controls or to the
absence of management controls which should have been in place.
Example 1:
The 3 year old child of an employee drowned in the swimming pool at a Company social
club. The requirement not to leave young children unsupervised had not been specified or
applied in this case. This would be considered a 3rd party work related fatality.
Injuries to employees participating in social events outside company premises are work
related if the events are organised by the company and the injuries result from a failure
of management controls. If injuries result wholly from the actions of the employees, e.g.
falling from a bar stool, they are not considered work related.
Acts of God and Wilful Acts
Injuries from “acts of God” such as being struck by lightning while at work are
considered work related.
Incidents occurring during the course of employment that are due to someone’s wilful
act are reportable, whether or not they occur on company premises.

Example 1:
An employee on a business trip was mugged after leaving a taxicab on the way to check-
in to a hotel. The injuries sustained are work related.
Example 2:
Two workers had a fight at the worksite. Any injuries sustained are work related.
Horseplay
Injuries arising out of horseplay during work are work related.
Example 1:
An employee was showing off by operating a forklift truck that he was not familiar with
or authorised to use. He lost control of the truck and struck a fellow employee. Although
the employee was engaged in a prohibited activity his injury and that of the fellow
employee are considered to be work related.

Appendix 13: Procedure for Reporting and Review of

All significant incidents, i.e. incidents with actual consequences to the company rating 4
or 5 on the Risk Assessment Matrix, shall be reported according to the procedure
detailed below. This pocedure applies to illnesses and injuries, including third party
fatalities, non-accidental deaths and deliberate deaths, and to incidents involving
damage to assets, the environment or company reputation.
Steps Action Party Timing
Notify the business Reporting company Within 24 hrs

To: business HSE adviser and relevant business director. of incident
Copies to: managing director for business, business chief
executive and Group HSE adviser.
Prepare investigation report Reporting company Within one month

According to Group guidelines, including Tripod analysis. of incident
Send to business HSE adviser (copy to Group HSE adviser
on request only).
Review investigation report Business HSE adviser Within two months

Review report for completeness and quality of investigation, of incident
identification of underlying causes and improvement actions.
If necessary request reporting company to improve the report.
Advise classification Business HSE adviser At end of review

Advise classification of incident to the reporting company and
Group HSE adviser. As process owner the Group HSE adviser
may review the classifications.
Significant incident review meeting Meeting participants: Within three months

A review meeting led by the business chief executive will be - Group managing director of incident
held for all incidents resulting in a company or contractor - Business chief executive
employee fatality, selected third party fatalities and all other - Relevant bus. director
HSE incidents with a significant impact. - Business HSE adviser
The review will consider the causes of the incident and (plus other expertise)
actions taken and planned. - Others decided by
business chief executive
Debrief Business HSE adviser Within one week

Prepare action items and lessons learned and copy to of review meeting
participants and Group HSE adviser.

Steps Action Party Timing
Follow up report Reporting company Within one year

This report will review implementation of action items from Business HSE adviser of review meeting
the investigation report and the significant incident review should remind company
meeting. Send copy of report to participants (to Group if necessary
HSE adviser on request only).
Review of follow up report Business HSE adviser Within two weeks

Confirm receipt and ask further questions as required.

Appendix 14: Exposure Hours - Examples
Appendix 14: Exposure Hours - Examples

The following examples are intended to clarify the definition and calculation of exposure
hours, to achieve a consistent approach in the calculation of injury and illness
frequencies.
Example 1:
An office worker lives in a suburban area and travels to work by public transport. This
person’s exposure hours would be the time spent at the office.
Example 2:
An office worker lives in a suburban area and travels to work in transport arranged by the
company. 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 company would be
considered a work related injury.
Example 3:
An employee travels on company business but in own time outside normal working
hours. This person’s exposure hours would be calculated on the basis of the normal
working week.
Example 4:
An employee is working scheduled and paid overtime. This person’s exposure hours
would include all overtime periods. Any unpaid overtime would be excluded.
Example 5:
An office employee is working unscheduled extra hours. Whilst in theory such working
time should be treated as in Example 4, it is generally not justified to keep records of
such working time for safety performance reporting. Hence, this person’s exposure hours
would be calculated on the basis of the normal working week.
Example 6:
A company employee or contractor works on an oilrig or supply boat. Only the on duty
hours are included in the calculation of exposure hours.
Note:
On company owned or time charter tankers exposure hours are calculated on the basis
of 24 hours per day, rather than the usual hours on duty. This is in-line with maritime
industry practice.

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Introduction

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002

Appendix 1: Definitions and Explanation of Terms 13

Appendix 2: Incident Classification and Reporting Flow Chart 18

Appendix 3: Medical Treatment Cases and First Aid Cases 19

Appendix 4: Distinguishing between Injuries and Illnesses, and Determining

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002

Reaction to Medical Treatment 27

Appendix 5 Classification of Occupational Illness 30

Appendix 6 Asset Damage - Examples 32

Appendix 7 Environmental Impact - Examples 33

Appendix 8 Reputation Impact - Examples 36

Appendix 9 Incident Investigation Guidance 37

Appendix 10 Sequentially Timed Event Plot - Example 41

Appendix 11 Incident Report Layout for a Significant Incident 42

Appendix 12 Work Related Activities – Guidance and Examples 44

Appendix 13 Procedure for Reporting and Review of Significant Incidents 50

Appendix 14 Exposure Hours - Examples 52

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002

1.1 Purpose and scope

The guiding principles for incident reporting are that:

This document provides guidance on the classification, investigation and reporting of

The reasons for revising this guide are:

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 1

1.2 Group Standards

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 2

2.1 Work Related Activities

Where it is impossible or inappropriate for the company to seek to apply management

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 3

The procedure to determine whether or not an illness is occupational is detailed in

The potential consequences of illnesses should be assessed on the RAM as described

2.4 Incidents Resulting in Asset Damage, Environmental Impact and/or

Incidents resulting in asset damage, environmental impact and/or impact on company

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 4

2.5 Near Misses

2.6 Potential Incidents

Potential incident data is frequently collected in the course of work-site inspections,

2.7 High Risk Incidents

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 5

3.1 Responsibilities and Competence

Investigation of incidents is a line responsibility. All investigations should be led by or

When conducting a detailed investigation and Tripod analysis, it is recommended that

Incidents occurring during activities controlled by contractors should be investigated by

3.2 Extent of Investigation

The extent of investigation of incidents should be based on a consideration of:

3.3 Investigation Process

The investigation should include the following activities:

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 6

Guidance on these activities is provided in Appendix 9. The checklists can be used as a

3.4 Establishing the Sequence of Events

3.4.2 Hazard-Event-Target (HET) trios

3.4.3 Sequentially Timed Event Plot (STEP)

3.5 Analysis of Underlying Causes and Weaknesses in Management System

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 7

3.5.1 Tripod for Understanding Incidents

3.5.2 Tripod Beta

3.5.3 Other methods

3.6 Incident Report and Follow up

3.6.1 Incident Report

Appendix 11 shows the recommended report format for an investigation of a significant

Incident Classification, Investigation and Reporting, Issue 2.0, February 2002 8

3.6.2 Legal advice

3.7 Communication of Lessons Learned