Incident Investigation Procedure.

NILAI, NEGERI SEMBILAN

Incident Investigation Procedure Ref No Edition

: :

PZ1-21 00

Issue Date

:

19th Mac 2014

Signature

Date

Name

Reviewed by

19th Mac 2014

Chong Hong Kong

Approved by

19th Mac 2014

Vasant Patil

Page

Page 1 of 5

Amendment

REF NO : PZ1-21

EDITION : 00

ISSUED DATE : 19th Mac 2014

PAGE : 1 OF 5

1.0 Purpose 1.1 The purpose of this procedure is to create guidance to conduct investigation for Major Accident in Recron. 2.0 Scope 2.1 This procedure covers all Major Accidents occurred within Recron Nilai Plant. 3.0 Definition NIL

4.0 Responsibility NIL

5.0 Details of Procedure

1. Team formation a. Incident investigation team are performed based on the incident category. Category

Team formation responsibility

Category A or fatality

The Site chief in consultation with Executive Director/GMS/CHSEE

B Category PFDE incidents or LWC/RWC

The site chief in case of large sites or the Sector Chief in consultation with the Team Leader.

C category PFDE incidents or MTC/FAC

HOD in consultation with team leader

a. Senior manager form affected area- Chairman b. Minimum team size-6 c. The team committee shall be trained in Root Cause Failure Analysis.

Page 2 of 5

REF NO : PZ1-21

EDITION : 00

ISSUED DATE : 19th Mac 2014

PAGE : 2 OF 5

d. Other members area based on the nature of the incident and could include :  Engineering and Maintenance Personnel ( Electrical, Mechanical and Utility)  HSE member  First line supervisor from the affected area  Involve employee / his representative  Individuals who have firsthand knowledge of incident  Other specialists (if required) 2. Determining Facts Types of evidences 1. Physical  Weather  Tools  Personal Protective Equipment  Machinery  Chemicals 2. Human  Employees  Supervision  Contractors  Vendors  Visitors 3. Operating systems  Training  Documentation  Rules/procedures  Preventive maintenance  Management of Change  Hazards analysis  Auditing  Communication  Culture 4. Gathering Information (interviewing) I. Introduction & establish report II. Judge state of mind III. Restate Purpose IV. Listen and demonstrate interest and concern V. Ask questions-what, when, where, why, who and how VI. Follow the sequence: General (open), specific, closed VII. Reflect meaning VIII. Reflect feeling

Page 3 of 5

REF NO : PZ1-21

EDITION : 00

ISSUED DATE : 19th Mac 2014

PAGE : 3 OF 5

5. Determining the key factors I. Funnel the information gathered II. Determine key factors by RCFA techniques III. RCFA (Root Cause Failure Analysis) identifies the causes of failures (i.e key factors) at Physical, Human and System levels. 

RFCA i. ii. iii.

principles First find physical key factors Next the human Key Factors Finally the system key factors

Key Factors Circumstances that contributed to or may be reasonably believed to have contributed to occurrence on the incident even though clear causal connection may not be found. 6. Determining systems to be strengthened The key factors should identify those systems, including PSM elements that need to be strengthened. a. Personnel  Training and performance  Management of change-personnel  Incident investigation and reporting  Auditing  Emergency planning and response  Contractor safety and performance b. Facilities  Quality assurance  Mechanical integrity  Pre-start up safety review  Management of subtle changes c. Technology  Process technology  Process hazard analysis  Operating procedures and safe practices  Management of change-Technology d. Operational discipline  Leadership by example  Sufficient and capable resources  Employee involvement  Active lines of communication REF NO : PZ1-21

EDITION : 00



Page 4 of 5

Strong team work

ISSUED DATE : 19th Mac 2014

PAGE : 4 OF 5

 Common share values  Up to date documentation  Practice consistent with procedures  Absence of shortcuts  Excellent housekeeping  Pride in organization 7. Recommending corrective and preventive actions a. Corrective and preventive actions should address all key factors and includes in the following  Description of action  Person responsible for implementation  Completion date  Should be acceptable to the implementing agency and affected plants  Recommendation date shall be decide with meticulous planning  Should be limited to the affected area  Learning’s from the incidents shall be taken up by the PSM chairman 8. Documentation and Communication a. Final incident Investigation report shall be send after 7 days from the accident. b. The learning from incident should also be part of the document review of PSM chairman. 9. Communication Shall be communicate to entire plant. 10.Follow-up Incident recommendation shall be follow up by the Person in-charge appoint and periodic report shall be establish to the Senior Site Head.

Page 5 of 5