Health, Safety, Security and Environment (HSSE) Management System

 

 

Health, Safety, Security and Environment (HSSE) Management System Issued Date:

xxxx

Document Title:  Incident Reporting & Investigation Procedure  

Revision No: 01

Document Number: SHER.SUB04

 

Table Of Contents

1.0 Purpose

2.0 Scope

3.0 Associated Documents

4.0 Purpose

5.0 Definitions

6.0 Procedure

6.1 Reporting Procedure

6.2 Personal Injury Reporting

7.0 Incident Number

7.1 Fatality

7.2 Critical Accidents/Incidents

7.3 Minor Accidents/Incidents

7.4 Non-Personal Injury Reporting

7.5 Near-Miss Incidents and Critical Near-Miss Incidents (Potential to be Serious)

7.6 Environmental Damage Reporting

7.7 Property Damage Reporting

7.7.1 Major / Serious Property Damage

7.7.2 Light Property Damage

8.0 External Reporting Procedures

9.0 Investigation Procedure

9.1 Determining Incident Severity

9.2 Determining Critical Incidents

9.3 Determining Required Level of Investigation

9.4 Fact Finding Guidelines

9.5 Causation; Root Cause Analysis

9.6 Corrective Action

9.7 Incident Investigation Report

9.8 Forms And Records

 

 

1.0 Purpose
   

The purpose of this program is to ensure that all Operational Support Services Company Limited (OSSCL) critical injury cases, medical treatments, first aid cases, near misses and environmental accidents/incidents are reported and investigated which will be used to prevent a recurrence of the same or similar accidents.

 

This procedure will also ensure that OSSCL comply with regulatory requirements relating to the reporting, investigating and correction of accidents/incidents and to collect accurate data for incident and injury prevention.

 

Operational Support Services Company Limited (OSSCL) is committed to the protection of its employees, the environment and its physical assets. OSSCL’s Management will continue to maintain a safe work environment in order to prevent occupational injuries and illnesses.

 

In the event of a critical incident the operations should be safely stopped for an investigation (Ref. to Stop Work Authority Procedure LII-HSSE-28).

Operations can only resume when instructions are received from the proper authorities. If similar conditions exist on other operations, the operations may be stopped until it could be assumed that the critical incident cannot be repeated.

This policy will be explained as needed to workers through HSSE Orientation, health & safety training or task-specific training.

 

2.0 Scope
   

This procedure applies to all employees, contractors, vendors and visitors;

 

§ Whilst present in any building or facility or on any site owned, occupied or managed by OSSCL;

§ In the course of, or as a result of, any occupational, educational, commercial, or OSSCL endorsed activity, whatever its location.

 

3.0 Associated Documents
   

§ Post Incident Procedure (LII-HSSE-27)

§ Stop Work Procedure (LII-HSSE-28)

§ Incident Management Procedure (LII-HSSE-29)

 

4.0 Purpose
   

Following the occurrence of an incident on OSSCL’s compound or Client’s facility, a three- phase process will be initiated:

 

1. Action will be taken to ensure the area is safe and medical attention will be provided if required.

2. The incident will be reported internally and externally as required by Law (OSH Act Part viii (46) and company procedure. In the event of an environmental issue the Environmental Act of T&T 2000 will be applicable.

3. The incident will be investigated.

 

 

 

5.0 Definitions
   

Near-Miss

 

A near-miss is an unplanned, undesired event that had the potential to result in personal injury, property damage, business interruptions and delay.

 

  Accident An accident is an unplanned, undesired event that results in unintended personal injury, property damage or loss, business interruptions or delay.

 

  Injury or illness covers any injury or illness incurred by any person whilst present on OSSCL compound, and any illness which is thought to be in some way related to the company. It includes the recurrence or aggravation of any pre-existing injury or illness.

 

  First Aid Immediate care rendered to persons who become sick or injured in the workplace.

 

  Medical Attention An injury that results in attention received from a recognized health care provider but does not result in time away from scheduled work or a wage loss.

 

  Fatality An injury that results in loss of life.

 

  Critical Incidents Critical incidents are those which cause or have the potential to cause serious injury. As defined in Part 1 Section 4 of the OSH Act 2004 (As Amended in 2006) it is a critical injury:

 

a) if the injury places life in jeopardy;

b) produces unconsciousness;

c) results in substantial loss of blood;

d) involves the fracture of a leg, or arm but not a finger or toe;

e) involves the amputation of a leg, arm, hand, or foot but not a finger or toe;

f) consists of burns to a major portion of the body;

g) or causes the loss of sight in an eye and/or fatality, significant structural damage and environmental losses.

 

  Lost Time A work related injury that results in the injured employee missing scheduled time from work resulting in a wage loss.

 

  Property Damage When there is significant property damage, a value of $50K is suggested as a general guideline to be used by a supervisor, although other factors could impact on the need and level of investigation and reporting.

 

  Occupational Illness A condition that results from exposure in a workplace to a physical, chemical or biological agent that impairs normal physiological mechanisms and the health of workers.

 

  Environmental Release Includes any disposing, spilling, emitting, leaking, or other incidence of discharge into the environment of any hazardous substance or pollutant.

 

 

 

6.0 Procedure
  6.1 Reporting Procedure
   

Only through open and honest reporting will it be possible to improve HSSE performance. All medical attention rendered on OSSCL compound (including “work related” or “non- work related” (First Aid)) will be accurately recorded in a First Aid Log. A copy of the log will be retained for a minimum of fifteen years at OSSCL’s Main Office.

 

  6.2 Personal Injury Reporting
   

All personal injuries occurring (including First Aid Cases) will be reported to the appropriate Supervisor as soon as possible. The Supervisor completes an Incident Report Form (LIII-HSSE-61) and submits it to the HSSE Advisor. The initial facts of ‘work related” First Aid Cases, Medical Treatment Case, Critical Injury Cases or Occupational Illnesses will be reported and must contain at least the following points when reporting.

 

§ Project Name

§ Location of the incident

§ Date and time of the incident

§ Name and position of injured

§ Initial diagnosis of the injuries sustained

§ Treatment given

§ Brief factual description of the activity at time of incident

§ Names of witnesses

§ Incident Number (see explanation below)

§ Initial actions taken

§ Current situation of injured

 

7.0 Incident Number
   

An Incident Number is assigned to all incidents reported. Incident Number is to be constructed as follows:

 

§ A sequential number is given to every incident as it occurs and the year in which it occurred e.g. 01/17 would indicate the first incident for 2017.

  7.1 Fatality
   

The CEO must be notified immediately by the fastest available means (i.e. telephone).

The initial factual points must be reported on the Incident Report Form (LIII-HSSE-61) and sent to the HSSE Advisor and CEO.

All fatalities must be reported to the OSH Authority in accordance with the OSH Act of T&T 2004 (Amendments 2006).

 

  7.2 Critical Accidents/Incidents
   

During business hours, immediately contact the CEO / Manager / Supervisor / HSSE Advisor/ or designee;

After hours immediately contact the CEO, HSSE Advisor and Manager/Supervisor.

A completed Incident Report Form (LIII-HSSE-61) must be sent to the HSSE Advisor within 12 hours of the incident.

All critical incidents must be reported to the OSH Authority in accordance to the OSH Act of T&T 2004 (Amendments 2006) and recorded on Accident/Incident Log (LIII- HSSE-62).

 

 

  7.3 Minor Accidents/Incidents
   

Ensure that the injured person has been immediately cared for.

 

§ Advise the C.E.O. and HSSE Advisor within 24 hours.

§ Ensure that an Incident Report Form (LIII-HSSE-61) is completed, signed and forwarded to the HSSE Advisor within 24 hours of the initial report. (Note: the original, hard-copy report must be sent with all required signatures. Unsigned documents are not acceptable).

 

A copy of the Incident Report Form (LIII-HSSE-61) will be placed in the respective individual file.

 

  7.4 Non-Personal Injury Reporting
   

All unsafe observations from employees, contractors, suppliers and visitors must be reported to the Supervisors or HSSE Advisor as soon as possible. These observations must be recorded and communicated to employees.

 

  7.5 Near-Miss Incidents and Critical Near-Miss Incidents (Potential to be Serious)
   

All Near Misses will be reported verbally by the person(s) who witnessed the event to their Supervisor. The Supervisor will document the incident on an Incident Report Form (LIII- HSSE-61) and report to the HSSE Advisor and the CEO.

 

Critical Near-Miss – Complete an Incident Report Form (LIII-HSSE-61) within 24 hours of the initial report. Based on the potential severity the Supervisor will determine to which level of management the incident facts will be forwarded. All critical forklift incidents must be reported to the OSH Authority.

 

  7.6 Environmental Damage Reporting
   

The reporting of all Environmental Incidents will be in accordance with the Environmental Management Act 2000, which in Section 61 states that as soon as the employer is aware of any release or other incident which the Act makes mention of, he is to notify the Environmental Management Authority and provide the following information:

 

§ brief description of the incident

§ assessment of potential damages or risk to human health and environment

§ description of response measures taken

 

  7.7 Property Damage Reporting
  7.7.1 Major / Serious Property Damage
   

The initial factual points will be reported immediately through the Senior Management and HSSE Advisor for further distribution to operations, relevant ministry department and insurance.

 

   

 

7.7.2 Light Property Damage

   

Any light property damage will be reported verbally by the person(s) who witnessed the incident to their supervisor.

 

8.0 External Reporting Procedures
 

 

 

Reports are made to external parties for incidents where there is critical injury only. The procedures outlined for external reporting in this procedure are in compliance with Section 46 of the OSH Act 2004 (as amended 2006).

 

8.1 OSSCL shall inform the OSH Authority of the accident/incident forthwith by telephone, facsimile, email, or other direct means and shall send a written notice of the accident/ incident, in the prescribed form and accompanied by the prescribed particulars, to the OSH Authority within forty-eight hours of learning of the accident/incident.

 

8.2 Where an incident which may be prejudicial to the safety or health of the public, or which has the potential of causing critical injury, including fire, explosion or the release of toxic substances occurs, OSSCL shall inform the OSH Authority of the incident forthwith by telephone, facsimile, email, and shall send a written notice of the incident to the OSH Authority within forty-eight hours of learning of the incident.

 

8.3 Where an accident, resulting in critical injury occurs and death follows the notification of the accident, a further notice in writing of the death shall be sent to the OSH Authority by OSSCL within forty-eight hours of learning of the death.

 

8.4 Where an accident causes injury to a person at a workplace whereby the person is unable to perform his usual work or requires medical attention, and such occurrence does not cause death or critical injury leading to disability, OSSCL shall give notice in the prescribed form within four days of the occurrence, to the OSH Authority, containing information and particulars of the accident.

 

8.5 If OSSCL is advised by or on behalf of an employee that the employee suffers from an occupational disease referred to in Schedule 1 in the OSH Act 2004 (As Amended 2006), OSSCL shall give notice in writing to the OSH Authority within four days of being so advised.

 

 

 

9.0 Investigation Procedure
  9.1 Determining Incident Severity

 

LIKELIHOOD

(Probability)

SEVERITY (consequences)
Slight 1 Minor 2 Serious 3 Major 4 Catastrophic 5
Frequent 5 5 10 15 20 25
High 4 4 8 12 16 20
Medium 3 3 6 9 12 15
Low 2 2 4 6 8 10
Negligible 1 1 2 3 4 5
Risk Rating
Intolerable 25  16 Substantial 15  10 Tolerable 9  5 Trivial 4 – 1

 

  OSSCL Risk matrix will be used to determine the potential risk of an accident/incident in order to ensure an appropriate level of investigation is conducted. The HSSE department along with the Department Supervisor will determine the severity of an accident.

 

The actual severity of an incident shall be considered according to its impacts on each of the three hazard categories (people, property/equipment damage-monetary value impact and environment), with the severity rating duly assigned to each. The more severe the outcome of an incident, the higher the numbers should be. The detailed definitions behind the summarized quotes on OSSCL’s risk matrix can be seen in the Risk Management Procedure.

 

To determine the potential risk of an incident using OSSCL’s Risk Matrix, follow the four simplified steps below

 

Step 1 Determine a potential severity rating from 1 to 5.

 

Step 2 Using all available historical information, determine a potential likelihood from 1 to 5. This figure refers to the likelihood of the potential severity (not the actual severity) occurring.

 

Step 3 Repeat the steps above separately for each matrix hazard category.

 

Step 4 The product of the severity rating and the likelihood rating should then be calculated and assigned to the Risk section.

Potential Risk = Likelihood x Severity

 

  9.2 Determining Critical Incidents
   

Critical incidents include those which cause or have the potential to cause serious injury (refer to definition of Critical Incident above). These incidents are ranked as intolerable on the Risk Assessment Matrix. These critical incidents include but are not limited to:

 

§ Incidents involving multiple injuries of multiple persons.

§ Incidents causing significant injury such as those requiring hospitalization, surgery or time away from work.

§ Incidents with the potential to fall into the critical incident category.

 

  9.3 Determining Required Level of Investigation
   

The greatest effort should be put into critical incidents as previously defined. These critical accidents/incidents demand more careful investigation and management time. This can usually be achieved by:

 

§ Looking more closely at the underlying causes of significant events.

§ Assigning the responsibility for the investigation of more significant events to more Senior Managers.

§ Ensuring that persons involved in critical incident investigation receive training in:

o Safety Management

o Hazard Identification

o Accident/Incident investigation

o Root cause analysis

 

Depending on the severity, or potential severity, of the accident/incident, the following persons may be asked by the CEO to lead or assist in the fact-finding investigation and preparation of a report.

 

 

Level of Investigation Personnel Involved
Trivial- Tolerable Risk Supervisors/Manager
Substantial Risk Supervisors, Managers, HSSE Advisor and Joint HSSE Committee
High risk Senior Management Representative, Supervisors, Managers, HSSE Advisor and Joint HSSE Committee

 

Where the circumstances determine the need of a specialist/technical person, management will appoint same.

  9.4 Fact Finding Guidelines
   

Investigation of an accident/incident is a fact-finding exercise only. No assumptions or analysis of the possible cause(s) should be made.

 

The intended purpose of these guidelines is to serve as a reminder of the issues that might be addressed during an incident investigation. The severity and circumstances of the incident will best determine if fewer (or perhaps more) questions / observations / documentations are appropriate. The guidelines will help keep you on the right track of documenting just the facts and avoiding opinions.

 

The key considerations when conducting an in-depth investigation include:

 

§ Be objective. Keep an open mind and maintain a neutral point of view.

§ You are on a fact-finding mission – report the facts only.

§ Do NOT form opinions, find fault, or place blame.

§ Do NOT speculate what the causes may have been.

§ Do NOT speculate what corrective actions might minimize occurrence.

 

Interviews:

 

§ Who witnessed the incident?

§ Where were the witnesses when the incident occurred? (Be Specific).

§ What did the witnesses see when the incident occurred? (Be Specific).

§ What did the witnesses hear when the incident occurred? (Be Specific).

§ What did the witnesses feel (physically) when the incident occurred? (Be Specific).

§ What instructions were given to each person prior to the incident and who gave the instructions? (All crewmembers, injured party, supervisors and other crewmembers).

§ Who was operating what equipment?

§ Where is the equipment located in association with the incident scene?

§ What inspections were performed prior to the incident, who performed them, and when were they performed? (list all equipment / material inspections and their findings).

§ What potential hazards were identified prior to conducting the task and what (if any) control measures were implemented to ensure it did not result in an incident?

§ What training had the injured party and / or other crewmembers received in conducting the operation underway at the time of the incident?

§ What instruction had the injured party and / or other crew members received in conducting the operation underway at the time of the incident?

§ How many times had the required injured party and / or other crewmembers previously conducted the operation underway at the time of the incident?

 

Observations:

 

§ What were the conditions of the work area where the incident occurred? (steps, grating, decking) be descriptive: steps are made of expanded metal and are free of grease and mud providing good traction).

§ What lighting was provided? (clear skies (8) 600W lights be descriptive: enough light to read).

§ What was the availability of help – mechanical services?

§ What (if any) barriers were in place at the time the incident occurred?

§ What (if any) lock-out/tag-out devices were in place at the time the incident occurred?

§ What personal protective equipment and clothing were being utilized by the injured party at the time of the incident? (boots, gloves, coveralls, hard hats, safety glasses, safety gloves, safety harnesses, retractable lines).

§ What was the condition of the equipment/clothing being utilized? (be descriptive: boots were free of oil and mud and provided good traction).

§ What was the availability of personal protective equipment/clothing

 

  9.5 Causation; Root Cause Analysis
   

§ Administrative Root Cause

§ Equipment Root Cause

§ Management Root Cause

§ Environment Root Cause

§ Behavior Root Cause

§ Ergonomic Root Cause

 

  9.6 Corrective Action
   

§ Recommended corrective actions shall be approved by Management and instruct Supervisor to take action.

§ Follow-ups reporting shall be done through the Supervisor or Departmental Head on the progress of corrective action.

§ Corrective actions shall be audited by relevant selected person(s) and report to Management.

 

  9.7 Incident Investigation Report
   

Base on the mandate, Management will review the accident/incident with the person in charge of the investigation team. If it is found to be lacking in any area or found to be unsatisfactory in any way, management would return the report to the investigative team for correction. When this process is completed and both parties are satisfied, management will instruct the person in charge of the investigation team to prepare copies of the report for the Joint HSSE Committee review and to distribute to the relevant authorities.

 

With the assistance of any persons participating in the investigation, the person in charge of the investigation will prepare a report of the following:

 

§ Facts surrounding and relevant to the incident

§ Details of the incident:

a) Was there a plan? If so, what was the plan? Who developed the plan?

b) What equipment, tools, materials were inspected? Who conducted the inspections? What were the findings of the inspections? etc.

c) What potential hazards were identified before, during, and after the incident occurred? Who identified these potential hazards? Who was informed of the potential hazards? etc.

d) Who was informed of the plan? How was the understanding by all involved or affected confirmed? etc.

e) What control measures were utilized to ensure the job was conducted safely (i.e., personal protective equipment, guards, barriers, warnings, work permits, isolations, supervision, etc.).

 

The report will be distributed at the discretion of the CEO, Manager/Supervisor or HSSE Advisor. A copy of the OSSCL’s report must be sent to the OSH Authority according to Part VIII of the OSH Act of T&T.

 

  9.8 Forms And Records

 

§ Incident Report Form (LIII-HSSE-61)

§ Accident/Incident Log (LIII-HSSE-62)

§ Medical Treatment/First Aid Log (LIII-HSSE-78)

Incident Reporting & Investigation Procedure REV01