Accident-Incident Reporting Procedure
ACCIDENT-INCIDENT REPORTING PROCEDURE
Document Revision Status
Nnochiri Ogbonna
0
15.06.13
Rev .
Date
Michael Nnanna
HSE COORDINATOR
GM-ENGINEERING SERV/ CORPORATE
Prepared
Reviewed
HAMMAKOPP CONSORTIUM LIMITED
HAMMAKOPP BASE
Km 25 Onitsha – Owerri Express Way Umuezedam Okija Anambra State. State.
[email protected]
2013
MD
Approved
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 2 of 26
TABLE of CONTENTS
INTRODUCTION
4
1.1
General
4
1.2
Objective of the Procedure
5
1.3
Purpose of the Procedure.
6
1.4
Definitions and Abbreviations.
7
1.5
References
7
2.0
Responsibilities
8
3.0
Incident Reporting, Investigation & Communication
9
Emergency Contacts
9
Emergency Flow Charts
10
4.0
Purpose Purpose of an Effective Investigation
.
11
5.0
Major Incident Notification Process
12
Incident Potential Matrix
15
Immediate Incident Notification & Reporting Matrix
17-18
Attachments Attachment 1 – Accident Reporting Form-Blank Copy
Incident Notification Form
Near-miss Reporting Form
Detailed Incident Investigation Report Format
19-26
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 3 of 26
REVISION HISTORY
Revision R0
Date Page
Description
Approved
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 4 of 26
INTRODUCTION General
Hammakopp Consortium Limited HSE Management System requires management commitment at all levels as to ensure that all accidents are prevented and unsafe conditions identified with control measures put in place to mitigate any undesired occurrence. Sound HSE MS implementation is geared towards accident prevention considering the high cost (direct & indirect) of accidents to an organization. Employees have the obligation to report unsafe acts and unsafe conditions, while HSE advisors conduct risk assessments jointly with construction team as to identify inherent hazards associated with all activities, and proffer controls as to prevent accidents. R e p o r t ab l e A c c i d e n t T y p e s ;
Fire Incidents
Medical Incidents
Security Incidents
Environmental Incidents
Equipment/Facility/Asset Damage Incidents
Direct costs of an accident are;
Medical Costs: Cost of treatment, additional associated medical costs, hospital and physician bills, occupational therapy, prescription medicine and medical equipment
Compensation Costs: Insurance, replacements, repairs and workmen compensation insurance policy implementations.
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 5 of 26
In d i r e c t C o s t s o f a n a c c i d e n t ;
Like an iceberg, the unseen indirect costs of accidents are much larger than the direct costs above. Indirect costs associated with workplace accidents and injuries include damage to the equipment the worker was using, loss of work time, production loss and cost to hire (a permanent or temporary replacement for the employee), training and retraining, cost of accident investigation, legal or police charges etc. Other indirect hidden costs include the possibility that the employer's insurance premium may raise rise because of the accident. Indirect costs associated with workplace accidents and injuries can total as much as three or four times the amount of the direct costs and may amount to 30 times the amount spent for direct costs, depending upon the type of accident that occurred.
Production delays/interruptions
Product and material loss or damage
Equipment or Facility Damage
Client Dissatisfaction
Employee Training
Overtime Costs
Loss in productivity
Corporate Image/media
So every effort must be made to prevent accidents from happening!
1.2
Objective of the Procedure
The objective and purpose of this document is to provide Hammakopp Consortium personnel with basic information that will serve as guidelines regarding standards of accidents and incident reporting and investigation. It attempts to establish and define responsibilities for different level of management as well as employee responsibilities in the event of an accident. It also defines the various levels of accidents as it relates to Hammakopp Consortium operations. Some details represented in this document may be revised from time to time to meet changes that may occur for various reasons. However, it is Hammakopp’s intention to adhere to this procedure as much as practicable.
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 6 of 26
1.3
Purpose of the Procedure.
This procedure will similarly fulfil the purpose listed below:
Documenting a procedure for accident reporting and investigation;
Establishing in clear terms reporting lines and timelines for reporting accidents
Provide the mechanism for rating accidents and their investigation levels
Identifying critical issues and potential constraints;
Defining responsibilities of the management and Employees
Facilitate the briefing of Hammakopp Consortium personnel and provide them with a guideline regarding accident reporting and investigation.
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 7 of 26
1.4
Definitions and Abbreviations.
N o n - c o n f o r m a n c e - A condition or event which deviates from established procedures.
Near Miss - an incident that does not result in loss but could have, given slightly different
(but credible) circumstances
A c c i d e n t - an unplanned, undesired incident which results in loss or damage to properties,
assets, equipments, facilities, environment etc. L o s s - The unnecessary waste of resources, including:
PEOPLE:
fatality, injury, illness
PLANT/EQUIPMENT:
damage, repairs, replacement
PROCESS:
interruption
AMENITY:
environment pollution
GOODWILL:
adverse publicity
1.5
References
Hammakopp Consortium Limited accident-incident reporting and investigation Procedure. Hammakopp Consortium Limited HSE Manual Hammakopp Consortium Limited HSE Plan for construction activities Accident report and investigation form. .
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 8 of 26
2. 0
RESPONSIBILITIES
Management-:
Ensure that all accidents/incidents and non-conformances are reported and documented.
Ensure that immediate and remote causes of accidents are identified, cascaded, and corrective actions taken to prevent the recurrence of an accident/ incident or non-conformance.
Ensure that unsafe conditions requiring management commitment are addressed as to prevent unwanted occurrence.
Ensure the provision of resources required to address accident related issues.
Ensure timely provision of emergency / contingency equipments.
Maintain effective communication with responsible parties in the event of an accident.
Ensure the mobilization of security personnel when required.
Employees
Ensuring their work activities does not harm themselves, others or the environment.
Take reasonable actions to prevent incidents and non-conformances.
Report incidents and non-conformances immediately to their supervisor.
Identify unsafe conditions, proffer immediate remedial actions or report unsafe conditions to their supervisor or HSE department.
Fill the HIR form when required.
Use fit-for-purpose equipments and tools to carry out work activities.
ERT/HSE
Initiates emergency response/ rescue operations
Communicates responsible parties and maintains effective communication
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 9 of 26
3.0
INCIDENT REPORTING, INVESTIGATION AND COMMUNICATION
Incidents are reported immediately to supervisors, HSE advisors and management depending on incident severity. The incident reporting and investigation form is used for reporting, investigating and tracking incidents to closure Lessons from and information on non-conformances and incidents are communicated using HSE Alerts, accident/incident review and HSE meetings and/or daily toolbox talks mediums. Emergency Contacts; NAME
DESIGNATION
PHONE
K. C AKUMA
MD
08033241099
NNANNA MICHAEL
GM Engr & Corporate Services
08036719422
CHUKWUNWIKE ALEX
GM Projects
08033402965
CHUKWUDUM IKENNA
Legal/SCD/Pro/Contracts
08034727156
FEROZ JADOON
Construction/Project Manager
08037936436
JOITI KUMAR
AGM - Maitenance
08030896640
HUSSEIN MOHAMMED
Senior Site Engineer
08160595035
WILLIAMS OLATOYE
Engineering Coordinator
08033150389
NNOCHIRI OGBONNA
HSE Coordinator
08036719585
ESIEKPE ISAAC
HSE Supervisor
07034547809
HENRY IWUCHUKWU
Chief Security Officer
08038804602
EWUZIE UCHE
Transport/Logistics Officer
08060824186
COKER MICHAEL
Asset Officer
08034934641
OGBONNA FRANCIS
Site Nurse
08075790861
MIRIAM IFEANYI
Base Nurse
07065322241
JUDITH OKOLI
HR Officer
08075790867
ALEX ISOGIE
HSE Officer-PH Base
08158990940
SOLOMON
HSE Coord- Uyo Base
08037534461
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 10 of 26
Emergency Flow Chart
MEDICAL /EVACUATION EMERGENCY REPONSE FLOW CHART Case Can be
Emergency Incident Observed at Site/Base/ Camp
Case Cannot be managed Internally
Call On-Scene HSE Co-ord, Site/Base managed Commandant Nurse will assess internally situation and take (OSC) action. GM. 08036719585/ 08036719422 07065322241 ,07028180801 or Code 1045 Case Cannot be managed Internally –Administer First Aid and Coordinate with Project Mgt. Team. GM-Projects-08033402965
Provide adequate First Aid or Med. Assistance.
Contact Client Site Rep.
PM/CM-08037936436
Medevac + Evacuation Required? Hamakopp to initiate Evacuation . Stabilize
Coordinate with Evacuation/ MEDEVAC Provider
Access the Situation & report
Communicate MEDEVAC Provider If needed
No need for MEDEVAC
Moves Victim to Hammakopp Retainer Clinic Important Lines
MD-07028002304,08033241099 DPR-084-3290000 &084-4611777 FEMENV-08032557931. Retainer Clinic- Our Lady of Lourdes Ihiala 08135700630 Retainer Clinic- PH-Meridian: 08063572178 8063572178
Phone Lines 08033241099---- -MD 08036719422------GM-Engr Services/Corporate 08033402965------GM-PROJECTS 08034727156------Legal/SCD/Pro/Contracts 08037936436------PM/Construction Manager 0816059503-------Hammakopp const. Abuloma 07065322241------BASE NURSE 08035973880 -----SITE NURSE 08036719585------HSE COORDINATOR 07034547809------HSE SUPERVISOR. 08063572178 -----Medical-Medridian Hosp-PH 08034877736-----HSE OFFICER-Abuloma, Site PH 08063487200----HSE OFFICER- Ichi Site, Anambra
Project Mgt. team to determine course of action
Investigate , Report & make Recommendations
Investigate &Report to Client 24hrs Contact Project Mgr to MEDVAC + Evacuate Victim
Inform MEDEVAC Provider
Inform the Base Office
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 11 of 26
PURPOSE OF AN EFFECTIVE INVESTIGATION.
4.0
A good and timely incident investigation can help us:
describe what happened
determine the immediate and root causes
evaluate the risks
develop controls
define trends
demonstrate concern
And which ultimately lead to:
4.1
fewer incidents
reduced incident costs
lower incident rates/potential
increased confidence /morale (client & employee)
higher profit margins
Which Incidents Shou ld Be Investigated?
We must investigate all incidents to determine which has the potential for major or serious loss! We should give special attention to those with high potential for loss
5.0
INCIDENT CLASSIFICATIONS
There are three major classes of incidents. 1) Major accidents 2) Serious accident
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 12 of 26
3) Minor accidents. MAJOR INCIDENT NOTIFICATION PROCESS.
Overview Hammakopp Consortium employees are responsible for preventing incidents by following safe and environmentally sound practices and procedures. When a Major Incident occurs, local employees’ first priority is to respond to the immediate needs of the situation and notify direct supervisors and managers to provide assistance with this response. Additionally, for Major Incidents, an immediate call to the operating base is required. The single hotline call ensures that support departments such as Legal, Contracts, Assets and Logistics, the HSE Departments, security and appropriate Management executives are kept informed of Major Incidents. This notification process reduces the burden on local management and personnel and allows them to be dedicated to emergency response and external notifications (e.g., responders, agencies, clients, etc).
5.1
MAJOR INCIDENT DEFINITION
Incident involving loss of life or major injuries (e.g., amputations, serious eye and head injuries, injuries requiring emergency hospitalization, etc).
Extensive property or equipment damage in excess of $50,000
Fatal road traffic accidents resulting to death(s).
Explosions, loss of radiation sources, or blows out events where Hammakopp Consortium personnel or equipment are present.
Fires requiring outside assistance from emergency services.
Radiation releases exceeding the reportable quantity
Chemical spills or releases that meet or exceed the l reportable quantity; any spills of 55 gallons (208 liters) or more which occur at a client’s facility, during
transport, or at a public location
Any incident involving Hammakopp Consortium employees, products or services at a client or Hammakopp Consortium location with likely public consequence or potential media attention
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 13 of 26
Security Incident: may include, but not be limited to threats to personnel or property (e.g., bomb threats), requiring the need to evacuate personnel from a location, reports of actual or threatened extortion, kidnapping of personnel or contractors, reports of civil, political, or labor unrest in a location.
Loss or theft of explosives or radiation sources.
Collapse of buildings
Natural disaster e.g flood, earthquake
5.2
SERIOUS ACCIDENTS DEFINITIONS
Any incident not mentioned in the previous definitions involving the following
Personal injury involving medical beyond first aid.
All days away from work cases
Fires handled by local staff
Property or equipment damage not exceeding $10,000 dollars
Chemical spills or releases that meet or exceed the local reportable quantity; any spills of 55 gallons (208 liters) or more occurring at Hammakopp Consortium base only.
5.3
MINOR ACCIDENTS DEFINITIONS
Any incident not mentioned in the previous definitions involving the following
Personal injury requiring first aid treatment.
Minor property damage (dents, broken minor glasses) between $1-$10,000 dollars.
Chemical spills or releases not exceeding the local reportable quantity; occurring at Hammakopp Consortium bases only.
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 14 of 26
5.4
HOTLINE CALL PROCESS
An employee involved in, or witnessing, an incident will report the incident to their supervisor. If the supervisor is not available the employee is to contact the local or local HSE Rep or the Site Manager (Reference emergency contact numbers). The supervisor, either alone or in conjunction with the local HSE representative and/or local emergency response coordinator, decides if the situation is a Major Incident. If yes, it must be reported to the responsible manager and the HSE Coordinator. This report must be made immediately after incident stabilization and at least wi thin two hours.
For severe incidents that do not appear to meet the exact definition or examples of a Major Incident, please use your best judgment and initiate a hotline call as appropriate. (When in doubt, always report) In situations where the major incident scenario is evolving (e.g., loss of source, employee hospitalization), the employee making the notification and/or the Emergency Coordinator is expected to make a follow-up notification to provide updated or closure information when appropriate. This information will be updated in the written record and communicated to the appropriate authorities. Phone calls must give the following-:
Name of Caller:
Caller’s contact number:
If caller is an employee, supervisor or other
Type of Incident:
Affected Employee Name:
Specific location ( site, customer site or other):
Address:
Description of the incident: A clear description of the incident must be provided by the caller.
Any immediate response need: Information on additional assistance that may be needed.
Other parties notified (Client, personnel, government agency, authorities, etc.)
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 15 of 26
5.5
INCIDENT POTENTIAL MATRIX Number of persons Involved.
Incident Severity.
0
1
2-10
11+
Major
1
Level 2
Level 1
Level 1
Level 1
Serious
2
Level 3
Level 2
Level 1
Level 1
Minor.
3
Level 3
Level 3
Level 2
Level 1
This matrix determines the investigation level of accidents in Hammakopp. However in arriving at this format, the major Considerations are as follows-:
the severity of the incident (or its potential); and
The number of persons involved (or its potential.)
Selection of investigation team members depend upon the determination of the severity of the incident.
5.6
WHO SHOULD INVESTIGATE INCIDENTS?
From the matrix above, these are the responsibilities as it applies to the different levels in accident investigation in Hammakopp Consortium Limited-: Level 1 Investigations are undertaken by the following-:
Line Supervisor/Manager.
Location or Project Manager/Project Engineer
MD/or management Rep.
HSE Coordinator/Manager.
Local HSE Representative
Others as deemed necessary (e.g., CSO, PRO/CLO, Asset/Logistics, staff personnel)
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 16 of 26
Level 2 Investigation is undertaken by the following-:
Line Supervisor/Manager - Leader
Group or Department Manager
Local HSE Representative
Others as deemed necessary (e.g., staff personnel)
Level 3 Investigations are undertaken by the following-:
Line Supervisor/Manager - Leader
Others as deemed necessary (e.g., staff personnel)
Supervisors should take the primary investigative role because they know:
An accident occurred in their area
The decision(s) made, equipment used, and other factors which may have caused the accident
The capabilities and limitations of the personnel involved in the accident
The procedures that were used or should have been used
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 17 of 26
5.7
HAMMAKOPP IMMEDIATE INCIDENT NOTIFICATION AND REPORTING MATRIX. INCIDENT SEVERITY MAJOR(within 2 hours)
PERSON TO CALL:
BASE/ENGINEERING
SERIOUS or Significant Near Miss(within 12 hours)
MINOR or Near Miss(within 24 hours)
CONTACT.
Name …………..............Michael Nnanna
Mobile phone:…..08036719422, 08075790844 PROJECTS
Mobile phone:…. ...08033402965, 08075790845
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
CONTACT.
Name …………...................Joythi Kumar Mobile phone:…................, 08075790872
LEGAL/SCD/PRO
Phone / verbal
CONTACT.
Name …………................Alex Chukwunwike
MAINTENANCE
Phone / email
CONTACT.
Name …………...................Ikenna Chukwudum
Mobile phone:…................08034727156,08075790846
CONSTRUCTION
CONTACT
Name …………. ................ .........N.F.Jadoon
Mobile phone….......... ...........08075790847 CONSTRUCTION PH BASE
CONTACT
Name …………. ..............Mohammed Hussain
Mobile phone….......... ...............08158990938 HSE
CONTACT.
Name ………… .................Nnochiri Ogbonna
Mobile phone…......08036719585, 08075790850 ASSET
CONTACT.
Name ………… ...............Micheal Bayo Coker
Mobile phone…......08034934641, 08075790862 TRANSPORT
CONTACT.
Name ………… ................Felix Ewuzie Uche
Mobile phone…......, ............ 08075790852
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 18 of 26
HAMMAKOPP HSE PH BASE
CONTACT.
Name ………… ..............................Alex Isogie
Mobile phone….........................., 08158990940 HAMMAKOPP HSE UYO BASE
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
Phone / email
Phone / verbal
Phone / verbal / e-mail
CONTACT.
Name ………… ..............................Solomon
Mobile phone….........................., 08037534461 CSO
Phone / email
CONTACT.
Name ………… ..................Iwuchukwu Hilary
Mobile phone….........................., 08075790868 EMERGENCY RESPONSE TEAM Name …………. Isaac Esiekpe-08075790851.
Name ..............Emmanuel Nworie-08063487200
CLINIC Name: Ogbonna Francis Name: Miriam Ifeanyi
CONTACT -08075790861 - 07065322241
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 19 of 26
ATTACHMENTS-:
ATTACHMENT I – ACCIDENT REPORTING FORM-BLANK ATTACHMENT 2 – NEAR-MISS INCIDENT REPORT FORM\ ATTACHMENT 3- DETAILED ACCIDENT-INCIDENT REPORT FORMAT
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 20 of 26
INCIDENT REPORT FORM
DATE OF INCIDENT:
TIME OF INCIDENT:
LOCATION OF INCIDENT: INCIDENT/ACCIDENT TYPE (TICK APPROPRIATE BOX) INDUSTRIAL
SECURITY
LOST TIME INJURY
COMMUNITY
MEDICAL TREATMENT CASE
ENVIRONMENTAL/SPILL
FIRE
NEARMISS
MARINE
OCCUPATIONAL HEALTH
ROAD TRAFFIC
OTHERS
NATURE OF SECURITY INCIDENT:
________________________________________
NATURE OF COMMUNITY INCIDENT:
________________________________________
STAFF/EQUIPMENT INVOLVED:
________________________________________
EVENT LEADING TO THE INCIDENT:
IMMEDIATE ACTION TAKEN: ____________________________________________________________________________________ ____________________________________________________________________________________ _________________________________________________________________________________ INCIDENT/ACCIDENT ANALYSIS/CONCLUSION: ____________________________________________________________________________________ ____________________________________________________________________________________ ________________________________________________________________________________ RECOMMENDATION:
NAME OF REPORTER
SIGN.
FURTHER INVESTIGATION REQUIRED? [YES/NO]
DEPT.
DATE
HEAD OF DEPT.
SIGN/DATE.
NOTE: THIS FORM MUST BE COMPLETED AND FORWARDED TO HSE COORDINATOR WITHIN 24HRS OF INCIDENT.
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 21 of 26
NEAR-MISS REPORT FORM PROJECT: ______________________________ LOCATION : ____________________
PLACE OF INCIDENT: ______________ DATE:_____________ TIME:______________
PERSONNEL INVOLVED INVOLVED
EQUIPMENT/MATERIAL
1. -----------------------------------------
1. ------------------------------------------
2. -----------------------------------------
2. ------------------------------------------
3. -----------------------------------------
3. ------------------------------------------
DESCRIPTION OF NEAR-MISS INCIDENT: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
IDENTIFIED REASONS FOR THE INCIDENT: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
REVIEW/RECOMMENDATION/LESSON LEARNT TO AVOID RE-OCCURRENCE: ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________ ____________________________________________________________________________________
REPORTED/OBSERVED BY: _________________ SECTION/DEPT._____________________
RECORDED BY: _____________ DESIGN:_______________
SIGN:____________
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 22 of 26
DETAILED INCIDENT INVESTIGATION REPORT FORM
1 – Anomaly/Incident Description Summary (Facts only) Enter here a brief description of the incident.
2 - Incident Classification Verification Date:
Time:
Activity:
Site:
Type
Exact Location:
Report Number:
Severity
Human Loss Classification
Damage Category
Anomaly Near Miss Incident
Human Loss
Actual
Potential
1 - Minor
Environmental loss Prod/Mat Loss Media
2Moderate
First Aid
1 - Minor
Medical Treatment Case
2 - Moderate
Restricted Work Day Case Lost Time Injury Multiple
3 - Serious
3 - Serious 4 - Major
4 - Major
Single
ith estimated
…w
5 - Catastrophic
_Days Lost
5Catastrophic
Illness
Fatality
3 - Incident Information 3.1 - Human Loss/Injury & Victim Information (remove section if not used) Name (s)
Age
Seniority date
COMPANY Contractor or Third Party
Job functi on
Hrs since last sleep
Hrs slept last time
Hrs on duty
Type of loss
Indicate details on injuries for each of the persons above
Injury A Cut B Heat Burn C Fracture/brea k D Amputation
Body parts affected
H Chemical burn I Sprain/strain J Bruise K Crushing
A Hea d B Fac e
H Fing ers I Leg s
Days lost (estimate d)
Medical Officer Name: _____________ Signature ______________
3.2 Vehicle Incident Information (Remove section if not used) Was vehicle travelling in convoy :
Yes
Was Vehicle
Rented/Leased
Company Owned
Weather Conditions
No
Was the driver the only occupant? Personal Vehicle
On Company Business
Road Type
Yes
No
Yes
No
Accident Type
Dry
Paved
Unpaved
Hit vehicle in front
Sideswipe
Wet/slick
Off road
Curve
Hit from behind
Passing
Clear
Up a grade
Downgraded
Backed into
Being passed
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 23 of 26
Dust
Narrow
Poor surface
Fog
Alcohol or drugs involved? (Testing required) Speed when accident occurred
Yes
No
______ km/h
Hit stationary object
Hit & Run
Hit pedestrian
Hit animal
Rollover
Ran off road
Results of alcohol test _____ g/l
Measured __ hrs after event
Driving Certificate held?
Yes
No
Driving monitor present and working?
Yes
No
Charged by Police?
Yes
No
All persons wearing seatbelts?
Yes
No
Defensive Driving Training up to date?
Yes
No
3.3 - Environmental Incident Information (Remove section if not used) Result
Details
Vegetation damage
Release to water way
Amount spilled or discharged:
Soil contamination
Released to air
Material name or code :
Marine life damage
Duration of discharge:
Ground water contamination
Unit
hrs
Min
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 24 of 26
3.4 - Asset, Material or Production Loss Information (Remove section if not used) Other Loss Information (Equipment, property, products, information, time or other including those of Third Party) Ty pe :
Description of loss
Quanti ty
Unit
4 - Incident Cost Estimate (Remove section if not used) Injury/Illness Costs ($000)
Automotive Costs ($000)
Environmental Costs ($000)
Other Costs ($000)
Lost Work Days
Replacement s
Lost Products
Replacement s
Temp Staff
Repairs
Remediation
Repairs
Medical Costs
3 Party Repairs
Litigation
Lost Products
Litigation/O ther
Litigation/Oth er
Other
Lost Revenue
Total
Total
Total
Total
rd
Remarks :
5 - Investigation Name of Manager leading the
Names of other team members:
Investigation Section 5.1 - Immediate Causes (Key Words) Contact/ Exposur
Fall Struck by Caught between Explosion or burns
N/A
Electrocution Drowning Vehicle incident Air transport incident
Marine Trans ort incident Gas leak Liquid hydrocarbon leak Other
Investigation Section 5.2 - Immediate Causes (Practices & Conditions) Unsafe
Procedure Failing to secure plant Failure to follow procedure Failure to warn of inform Operating at improper speed erformin hazardous liftin or loadin Inade uate Guards or Barriers Inadequate PPE Defective Tools, Equip, or Mat. Congestion / Poor Access Inadequate Warning System Inadequate Illumination
Unsafe Situation
Material tools & e ui ment Using Unsafe Use of Correct Tools / Servicing equip in Failure to check equip Dru induced Pressure ex osure Slippery surface Defective Plant / Wear and tear Radiation exposure Hazardous Atmospheric
Unsafe Position / Posture Unsafe Loading / Lifting Horseplay Failure to Make Plant Safe Unsafe Mixing, Placing, Servicin e ui in o eration Substandard Housekee in Corrosion / Slow Damage Excessive Noise or Inadequate Ventilation Safety devices inoperable
Investigation Section 5.3 - Root Causes (Which of the following Human and/or Job Factors were the Basic Causes of this accident?) Job Factors
Human Factors Lack of knowledge Inadequate capability
Inadequate Training Improper Motivation
Inadequate Leadership / Supervision Inadequate Engineering
Inadequate Job Planning Inadequate tools, materials, equip.
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 25 of 26
Stress
Fatigue
Substance Abuse Lack of Awareness
Inadequate Purchasing
Inadequate Work Standards
Inadequate Work Instructions Procedures
Inattention Lack of Sleep
Inadequate Risk Assessment Inadequate Definition of Responsibilities
Inadequate Maintenance Inadequate Plant/Machinery/Equip. Abuse or misuse
Investigation Section 5.4 - Root Cause (Refers to MS Dysfunction)
The fundamental or root causes are selected from one of the 14 elements listed below Respect of laws & regulations Management Responsibilities Operational Responsibilities Risk Evaluation & Management
Respect for the Environment
Emergency Preparedness
Safeguarding of Health
Incident Analysis
Contractors & Suppliers
Audits & Inspections
Competence & Training
Criminal act / ill will Other
Performance Improvement
6 - Other Information (Interviews, Pictures, etc.)
Include in this section a summary of all the information collected during the investigation. Place supporting documents at the end of the report – as Appendix. 1) 2) 3) 4)
Winess Report Preliminary Incident Notification Investigation Report Photograph
7 – Cause Tree Analysis State Causes (FACTS-ONLY)
Insert the cause tree analysis in this section.
8 - Corrective Actions Enter below corrective actions required to address immediate, basic and root causes. Specify WHO and WHEN.
Item No 1 2 3
Action Item Recommendation
Person Responsi ble
Target Date
Complet ion. Date
Remarks
Accident - Incident Reporting
Doc. No.:
Procedure.
Rev. No.:0 Page 26 of 26
9 - Review and Endorsement
Comments by Reviewing Manager
Endorsements
Reported By (Name):
Signature:
Date:
Noted By (Name):
Signature:
Date:
For HSE Division:
Signature:
Date:
