Accidents / Incidents

Investigation and Reporting

BY
FAWZY SHAABAN

Introduction
Why HSE is important ?

Protect your production basic elements

Equipment , Material and Environment

Workers ,

HSE regulations is sound barrier between the production

resources and the workplace hazards .

Accidents and injuries are more expensive than any realize.

The production objectives & accident prevention can not be
achieved without sound HSE management.

Introduction
HSE APPLICABLE LAWS

law of labor No.12 for 2003 Book five

concerning occupational health and safety

The social Insurance Law No.97 of the

year 1975

law No.4 for 1994 concerning the

environment

HSE MANAGEMENT SYSTEMS

HSMS
OHSAS 18001

EMS
14001

HSE MANAGEMENT SYSTEMS MODEL

CONTINUAL
IMPROVEMENT HSE Policy
Planning
Management Review

HSE Aspects
Legal & Other Requirements
Objectives & Targets
HSE MGT Programmes

Implementation & Operation

Checking & Corrective Action

Monitoring & Measurement

Incident investigation ,

Corrective & Preventive

Actions
Records
HSEMS Audits

Structure & Responsibility

Training, Awareness & Competence
Communication
HSEMS Documentation
Document Control
Operational Control
Emergency Preparedness
& Response

Active and Reactive Monitoring

Active Monitoring
Workplace inspections
Safety samples
Safety tours
Safety surveys

Audits
Monitoring progress

Reactive Monitoring
Accident and incident
investigation
Near misses incidents
investigation
Dangerous occurrences
Incidents / ill-health
statistics

Monitoring failure

Introduction
The reporting and investigation of incidents is
intended as a tool for continual
improvement, through the gradual elimination
of identified problems.

It is the responsibility of any employee who

has direct involvement in, or who witness an

incident to report the incident .

Introduction
The employees direct supervisor shall

assist with the initial report, if required.

Incidents shall be classified and

investigated according to their type and

category.

INTRODUCTION

The categorization, level of

investigation and its timing shall reflect

the severity and actual or potential
consequences of the incident.

Recommendations for corrective and

preventive action shall be made when

investigation findings are complete.

INTRODUCTION
A good record-keeping system can help
the safety professional in the following
ways:
Provide safety personnel with the means
for an objective evaluation of the
magnitude of their accident problems.
Measurement of the overall progress and
effectiveness of their safety programs.

Introduction
Identify high rate units, plants or
departments and problem areas, so extra
effort can be made in those areas.
Provide data for an analysis of accidents
and illness, which can then be attacked by
specific actions.
Create interest in safety among supervisors
by furnishing them with information about
their departments accident experience.

DEFINITIONS

FATALITY
Means a death resulting from a work injury,
regardless of the time intervening between
injury and death, or damage in property
exceeding certain amount ( U.S. $ 500.000

LOST WORK DAY CASE ( LWC )

LWC is the case, which involves day (s) away
from work or day (s) of restricted work
activity or both

DEFINITIONS

MEDICAL TREATMENT CASE (MTC)

Means any work injury that involves neither
lost workday(s) nor restricted workday(s)
but which requires treatment by or under
the specific order of a physician.

OCCUPATIONAL ILLNESS
Any work related abnormal condition or
disorder (Means any illness resulting from
employment

Definitions
PERMANENT PARTIAL DISABILITY (PPD)
Means any work injury, which results in the
complete loss, or permanent impairment of
functions of parts of the body, regardless of any
preexisting disability of the injured member or
impaired body function.

PERMANENT TOTAL DISABILITY (PTD)

Means any work injury which incapacitates an
employee permanently and results in termination
of employment.

Definitions
WORK INJURY
Means an injury that result from an
accident occurring during the
performance or because of the work ,
and also contracting one of the
occupational diseases as indicated in
table No.(1)as attached to the Social
Insurance Law No .97 for year 1975and
MD 1/2004

Definitions
High Potential Incident ( HIPO )

This is the number of high potential incidents per

million exposure hours. A high potential incident is
any incident which had the potential for multiple
fatalities (category 1) or a single fatality (category
2)

Road Traffic Accident ( RTA )

This is the number of road traffic accidents (or

incidents) per kilometer driven. A road traffic
accident is any accident (or incident) involving a
vehicle of any kind where the damage to the vehicle
is in excess of $1000 or persons are injured.

DEFINITIONS
LOST TIME INJURIES (LTI)
Means sum of fatalities, permanent total
disabilities, permanent partial disabilities and
lost workday cases.

LOST TIME INJURY FREQUENCY (LTIF)

Means number of lost time injuries per million
exposure hours during the period.

SEVERITY ( S )
Means number of man days lost by injuries per
million man hours worked

DEFINITIONS
Hazards : Source or situation or acts with a

potential for harm in terms of injury or ill health,

damage to property, damage to work place
environment, or a combination of these

Hazard identification : Process of recognizing that a

hazard exists and defining its characteristics.

Risk : It is the chance low or high which somebody

or something can harmed by the hazard
Combination of the likelihood and consequences

Risk assessment : Overall process of estimating the

magnitude of risk and deciding whether or not the
risk is tolerable.

DEFINITIONS ( CONT ,)

ACCIDENT :

UNDESIRED EVENT GIVING RISE

TO DEATH , ILL HEALTH, INJURY, DAMAGE OR
OTHER LOSS

INCIDENT :

EVENT THAT GAVE RISE TO AN

ACCIDENT OR HAD THE POTENTIAL TO LEAD TO
AN ACCIDENT

NOTE : An incident where no ill health, injury,

property damage or other loss occurs is also
referred to as a near miss

ACCIDENTS

INCIDENTS
NEAR MISS

HI PO
INCIDENT

HAZARDS CLASSIFICATIONS

Hazard Identification
There are two general types of Hazards:

Built-In
Hazards

Built-On
Hazards

Hazard Pyramid and Ice Berg Theory

Employee hits head on edge of desk

while falling and breaks neck. Dies
Fatality

LTA

Medically
treatable injury

Employee fractures arm as he hits

the floor. 2 weeks sick leave
While falling, employees body
grazes edge of metal drawer
and lacerates arm. 4 stitches

Near miss Incident

A second employee slips

on spill, falls, and gets bruised.

Unsafe acts & Unsafe conditions

Employee spills oil on

floor and walks away

Accident Studies
All accidents whether major or minor are caused.
Minor accidents have the same root causes as serious
accidents , the severity is often a matter of chance.

Accidents studies have shown that there is a

consistently greater number of less serious accidents

than serious accidents and in the same way a greater
number of incidents than accidents.

Accident Studies
In all cases the non injury incidents had the
potential to become events with more serious
consequences.

Such ratios clearly demonstrate that safety effort

should be aimed at all accidents including unsafe

practices at the bottom of the pyramid, with a
resulting improvement in upper tiers.

Peterson (1978) in defining the principles of safety

management says that an unsafe act, an unsafe

condition, an accident are symptoms of something

wrong within the managements system.

Hazards Identification & Risk Assessment

HAZARDS CLASSIFICATIONS
Physical hazards
Chemical hazards

Mechanical hazards
Fire hazards

Passive hazards
Biological hazards

Hazard Classification List

1204-100
REV.3
Sept. 20.2004

Physical (A)

Chemical (B)

Mehanical(C )

Fire (D)

Passive(E)

A1 Noise/vibration

B1 Asphyxiate Gases

C2 Machines ,Equipment
Tools, etc

D1 Lack of fire
protection Equipment
system

E1 Lack of Training

A2 Heat stress/Cold

B2 Toxic & Carinogenic

Material

C3 Construction activities (
Note )

D2 Lack of passive fire

protection

E2 Lack of emergeny &

Evacuation plan/Tools

A3 sociological Stress B3 Flammable Gases

C7 Material Handling and

lifting

E3 Lack of Awareness

A4 Hazard & Harmfull

Radiation ( Laser ,
ionized ,and ultraviolet
radiations )

B4 Special Chemicals

C8 Falling/Flying Objects

E4 Lack of Supervision

A5 Illumination

B5 Acids

C9 Transportation Means

E5 Lack of Protection

B6 Alkalines

C10 Mining and Quarry

activities

E6 Lack of Guidance

A6 Static Electricity

Hazard Classification List

A7 Deleted Note (2)

B7 Organic Solvents

C11 Diving & Working under

water and sailing

E7 Lack of Precaution

A8 Ergonomics

B8 Flammable Liquid

C12 Explosives

E8 Lack of Maintenance

A9 Variartion of
Atmospheric pressure

B9 Hazardous Dust/Solid

C13 Storage activities and

handling

E9 Lack of Procedures

C14 Dynamic Electricity

E10 lack of Housekeeping

E11 Lack of first Aid

E12 Lack of Health
Certifiates
E13 lack of
safety data sheet

Biological(F)

F1 Biological impact
(bacteria,Virus,Fungi
Algae,Parasites,
Biological hazards
materials And
Biochemical hazards
Note ( 2 )

Mechanical Hazards
Entanglement
Traps
Shearing, drawing
in & crushing

Impact
Contact
Friction / abrasion,

cutting & stabbing /

puncture

Ejection

ENTICE

Hazards of Electricity

Burns
Shock
Arching
Fires
Explosions

Be SAFE

HAZARDS EFFECT
Injuries
Occupational illness ( ill health )
Property Damage

Damage to work environment.

Company reputation.

Risk Screening and

Assessment Process

Identify the
Hazard

Analyze
The Risk

Evaluate
the Risk

Control
The Risk

Record and
Review

How Is Risk Estimated?

LIKELIHOOD

measure of the frequency at

which an event might occur

SEVERITY

measure of the adverse

effects of an event

RISK

LIKELIHOOD

SEVERITY

For an event

Factors Affecting Likelihood

Number of times situation occurs
Duration of exposure
Quantities of materials involved
Environmental conditions (lighting,
temperature)

Competence of people involved

Condition of equipment

Risk Control
Hierarchy of control

Eliminate
Reduce

Safe
Place

Isolate
Control
PPE

Discipline

Remember ERICPD

Safe
Person

Incidents Investigation

Why Investigate?

Prevent future accidents

Identify management system weaknesses
Prevent business loss
Best practice compliance
Collate data and establish trends
Defend civil claims
Defend a criminal case

Incidents Investigation
An incident with any of the consequences

listed below shall be investigated in depth to

identify all causes and to recommend hazard
control measures.

a. Fatal injury
b. Five or more persons admitted to a hospital
c. Property damage
d. Impact to environment.

Incidents Investigation
The investigation shall be made by the

supervisor, worker familiar with process

involved and site safety officers (HSE
coordinator).

Each investigation should be made as

soon after the accident as possible.

A delay may permit important evidence

to be destroyed or removed.

Incidents Investigation
Cases to be Investigated:

An incident causing death or serious injury

should be investigated.
The near - miss that might have caused
death or serious injury is equally
important and should be investigated (For
example, a broken crane hook).

Domino Theory
A

E
A
B
C
D
E

=
=
=
=
=

Root causes - Lack of management control

Basic or underlying causes - Individual and job factors
Immediate causes - Unsafe acts and conditions
Accident
Loss

Incident Types
Slips / trips / falls on
same level

Falls from height

Falling objects
Collision with objects
Trapping / crushing
Manual handling
Machinery contact

Electricity
Transport
Chemical contact
Asphyxiation /
drowning
Fire and explosion
Animals
Violence

Incidents Investigation Scope

The investigation scope shall cover the
following :

Environment
Equipment
Procedures
People
Organization

ACCIDENT / INCIDENT INVESTIGATION

PROCESS
12345-

NOTIFICATION .
ASSIGEN INVESTIGATION TEAM.
PREPARATION.
SITE VISIT .
FACT FINDING OR CONTRIBUTING
FACTORS
6- INFORMATION GATHERING .
7- ANALYSIS OF INVESTIGATION FINDIGS.
8- RECOMMENDATIONS.

NOTIFICATION
TIME , LOCATION AND NATURE
ACCIDENT.

PERSONS INJURIED
IMMEDIATE ACTIONS TAKEN
ASSISTANCE REQUIRED

ASSIGN INVESTIGATION
TEAM
TEAM LEADER ; DEPARTEMENT MANAGER AND /OR

SITE MANAGER .
SUPERVISOR FROM CONCERNED DEPARTMENT .
TWO MEMBERS FROM OTHER
DEPARTMENTS OR SITE
DISCIPLINES SELECTED
BY TEAM LEADER.
ONE MEMBER FROM CONSTRUCTION CONTRACTOR
AND HIS HSE COORDINATOR IF INVOLVED IN THE
ACCIDENT.
HSE MANAGER .

PREPARATION
LOCATIONS PLANS
ORGANIZATION AND PERSONS

INVOLVED
GENERAL PROCEDURES FOR THE
OPERATOIN INVOLVED.
CAMERA
CHECKLIST TO KEEP THE FULL RANGE OF
INQUIRY IN MIND.

SITE VISITE
INVESTIGATION SHALL BE CARRIED OUT BY
USING PRELIMINARY REPORT.

REVIEW THE WORK IN PRGRESS DURING THE

ACCIDENT TO IDENTIFY EVENT SEQUENCES .

COLLECTING EVIDENCES , INFORMATIONS

PHOTOGRAPHS , SKETCHES AND NOTES.

EFFECTIVE USE OF WITNESS.

Preliminary Site Visit.

The first to be considered is the potential

hazards during preliminary site visit such as

the following:
Thermal hazards.
Mechanical hazards.
Chemical hazards.
Electrical hazards.

Accident Investigation
The sources of information are:
Observations at the scene of the accident.

Interviews.
Written instructions and procedures.
Records.
Reports of specialist investigations.

FACT FINDINGS OR CONTRIBUTING FACTORS

ENVIRONMENTAL
DESIGN
SYSTEMS & PROCEDURES
HUMAN BEHAVIOUR

CONTRIBUTING FACTORS
ENVIRONMENTAL

NOISE
VAPORS, FUMES, DUST
LIGHT
HEAT

CONTRIBUTING FACTORS
DESIGN

Workplace layout
Design of tools & equipment
Maintenance

CONTRIBUTING FACTORS
SYSTEMS & PROCEDURES

LACK OF SYSTEMS & PROCEDURES

INAPPROPRIATE SYSTEMS &
PROCEDURES

CONTRIBUTING FACTORS
HUMAN BEHAVIOR

Common to all accidents

Not limited to the person involved in the
accident

Information's Gathering

1- Isolate accident scene , photos &

sketches should be taken , and do not

discard any things.

2- Obtain information from :

-

injured person
Witnesses
Supervisors
Any persons

Information's Gathering
3- Make interviews separately
Ask open-ended questions
What did you see?
What happened?

Do not make suggestions

If the person is stumbling over a word or
concept, do not help them out

Cont,interview
Use closed-ended questions later to gain
more detail.

After the person has provided their

explanation, these type of questions can be
used to clarify

Where are you standing?

What time did it happen?

Cont, interview
Dont ask leading questions
Bad: Why was the forklift operator driving
recklessly?
Good: How was the forklift operator
driving?

Ask the witness/victim for

recommendations to prevent recurrence

These people will often have the best

solutions to
the problem

Cont, interview
Get a written, signed statement from
the witness

It is best if the witness writes their own

statement; interview notes signed by the
witness may be used if the witness refuses
to write a statement

Cont( Information's Gathering )

4- Compile procedures & rules for the area.
5- Gather maintenance Records on
equipment involved.
6- Isolate essential contributory factors ,
the investigation team shall:
* Evaluate all factors concerned.
* Isolate the factors by asking the
following question : would the accident
have happened if this particular factors
are not occurred ?

Analysis of Investigation Findings

Analysis of Investigation Findings.

The purpose of analyzing is to establish the

sequences of critical events and the underlying

causes of the accidents and its consequences.

Effective investigation needs to seek the causes

behind the causes (i.e. defects in the system for

planning , controlling and executing the work).

Analysis of a group of accidents can highlight

pattern or trends of types of accidents or
accident causes, so that safety efforts can be
focused on recurring causal factors or
recognizable hazard areas.

Fault Tree Construction

Accident / incident analysis

1- Interpret & Draws conclusion from gathered
information and fact finings.
2- Identify immediate ,Basic causes and root causes by
using the investigation result sheet form.
3- Make recommendations based on key contributory
factors and root causes
4- Recommendations must be communicated clearly.
5- Follow up recommendations ( actions required,
responsible persons or dept. and completion dates )

Accident Investigation
The investigator should use the following
guideline to determine the following:
Immediate causes.
Basic Causes.
Root causes.

Immediate Causes
.

Immediate Causes
Nearly every accident that results in an
injury is caused by two things:

Unsafe
Condition

Unsafe
Actions

Immediate Causes
Unsafe actions are such as:
Failure to warn or educate.
Failure to secure.

Operating outside of design limitations.

Removing a safety device using defective
equipment.
Not wearing personnel protection
equipment.

Immediate Causes
Improper lifting technique
Improper position for task.
Servicing equipment in operation.
Horseplay or other non-work related
activity.
Under influence of alcohol, drugs,
medication.

Immediate Causes
Unsafe Conditions are such as:
Inadequate/improper protective
equipment.
Defective tools, equipment or materials.
Congested or restricted areas of work.
Inadequate warning systems.
Chemical hazards.
Housekeeping.

Immediate Causes
Noise exposure.
Radiation exposure.
Temperature extremes.
Poor / excessive illumination.
Ventilation inadequate.
Other identified features.

Basic Underlying Causes

Basic Causes
Basic Causes : These are the underlying factors,
that led to the unsafe act or condition and may
include the following
Failure to react to an unusual situation (training
of new procedure, personnel, equipment,
process, and/or material).
No instruction provided or available.
Failure to correct existing situation.
Instruction/training inadequate or not
understood.
Supervision failed to tell why.

Basic Causes

Supervision failed to listen.

Duties and task not clear.
Pressure of immediate tasks.
Responsibility not clear or understood.
Too many decision makers giving instruction.
Authority inadequate to manage the situation.
Decision avoidance.
Morals, tension and stress causing situations.

Basic Causes
Job descriptions not adequate
Human error, wrong action taken.
Lack of co-ordination/team work.
Poor co-operation.
Faulty inspection and maintenance.
Poor work control/co-ordination leading to
poor site conditions.
Work load too much/too little

Basic Causes
Staff shortages high turnover/absenteeism
Personality type e.g., impulsive, excitable,
lazy etc.
Poor work habits, taking short cuts,
careless with tools.
Work assignment unsuitable for the
particular individual.
Inadequate delegation or subordinates.
Health and impairment of the individual.

Root Causes

Root Causes
Root Cause : The Cause that , if corrected , would

prevent recurrence of the accident and similar

occurrences .
The general failure types of the accident cause chain can
be listed as follows:Procedures.
Conflicting targets.
Communications.
Hardware .
Training.
Organization.
Maintenance.

Root Causes
Procedures.
Inadequate quality of existing procedures
regarding application, availability, realism and
understanding caused by:

Inadequate team that developed the procedure.

Inadequate feedback about the procedure.
Personnel not informed about procedures.
Inadequate Document Control .
Lack of requirement to have tasks procedures.

Root Causes
Conflicting targets - caused by:
Conflict between production and safe working
practices.
Conflict between financial priorities and safe
working practices.
Conflict between individual priorities and safe
working practices.

Root Causes
Communications - difficulties caused by:
Language problems cultural barriers.
Lack of clear lines of communication.
Inadequate feedback (e.g. toolbox talks).
No standardization of information formats.
Lines of communication overloaded.

Root Causes
Hardware - quality, availability of tools and
equipment caused by:

Inadequate specification of equipment.

Wrong components purchased / used.
Equipment may not be available leading to
improvisation.
Defective equipment.
Age of equipment compared to life expectancy.

Root Causes
Training Shortcomings in skill and knowledge caused by:

Ineffective pre-employment selection.

Prior education not compatible with job requirements.
No structured planning of training programs.
No assessment of training effectiveness.
Ineffective training.
Training not appropriate for the personnel .

Root Causes
Organization Shortcomings in the structure of the organization
leading to inadequate operation of a company or
project caused by:
Inadequately defined departments or parts of the
organization.
Unclear accountability, responsibility or delegation
structure.
Inadequate definitions of objectives and co-ordination
of project and tasks.

Root Causes
Maintenance - Inadequate management of
maintenance and repairs caused by:

Inadequate planning, controlling, execution

and recording of maintenance programs.
Shortage of maintenance personnel.
Shortage of maintenance tools.
Shortage of maintenance supervision.

Incidents Reporting , Recording And

Rates

Incident Investigation Form

An incident investigation is not completed

until a report is prepared and submitted to

proper authorities .

Special incidents investigation report

forms shall be used , but some incidents

may require a more detailed report .

NEAR MISS FLOW CHART

Near Miss

Initiator to report Near Miss by using Near Miss

form (Library /Nt server 2/ appl / Word Pro/
Standard_forms / HSE_DS/Near Miss Report
Form)

Line supervisor to review the Near Miss Report and

determine The immediate Causes, Root Causes and
The Required Corrective and Preventive Actions

HSE Manager/Site HSE Coordinator to Review

Immediate Causes, Root Causes and the required
Corrective and Preventive actions

Concerned Department
For implementation the
corrective and preventive
actions that required

Action Tracking Register

For recording and follow-up the
Near-Miss report by
(Headquarters/site) HSE
Coordinator

(Headquarters/site) HSE
Coordinators to ensure and
check the implementation of
Corrective and Preventive
Actions

Electrical

Near Miss analysis,

April 2004
work at height
8%

civil work
7%

Electrical
10%

Welding/Grinding
Use of equipment/Machinery

Welding/Grinding
20%

Excavation
9%

Transport
Scaffolding/Ladders
Sand plasting/Painting

Confiend Space
3%

Lifting/ Crane operation

House Keeping
Handling of goods/ Materials

Maintainenace
9%

Handling of
goods/ Materials
3%

Sand plasting/Painting
3%

Transport
7%
Use of equipment
/Machinery
2%

Maintainenace
Confiend Space
Radio graphy

Lifting/ Crane operation

11%
Scaffolding/Ladders
9%

Excavation
work at height
civil work
others

ACCIDENT/INCIDENT NOTIFICATION, REPORTING AND

INVESTIGATION CHART

Any Accident / Incident

All Employees report immediately

Line Supervisor

For Minor Injury

Fill Form of First Aid / Medical
Report Form (Library NT Server
2/appl/word pro/ Standard_Forms
/HSE_DS /First Aid / Medical
Report) Form

Enppi Doctor or Site Doctor to

take the necessary actions for
Injuries/Illness

Department/Site Manager

Division Manager/HSE
Manager

Any fatality, Serious Injury and

Major Property Damage shall
initiate investigation team.

For Major Injury within 24 hours complete

Accident / Incident preliminary report ( Library NT
Server 2/word pro / Standard_Forms / HSE_DS
Accident / Incident preliminary report form )

Investigation team to identify Root

Causes
and
Remedial
Actions,
responsibilities and completion dates
with reference to risk assessment

The
Investigation
team
leader
shall
approve Accident / Incident Investigation
Result
Sheet
(libraryNTserver2/word
pro/standard
forms/HSE_DS/
accident/
Incident
investigation
result
sheet)and
arrange for corrective actions
Department
Manager,
site
Manager and HSE Coordinator
ensure follow-up of actions and
lessons
learned
are
widely
communicated

Completion of Corrective
And Preventive Actions

Confirmation of Effectiveness
of Corrective and Preventive
Actions Taken

Actions shall be reviewed through risk

assessment process to Implementation

ACCIDENT /INCIDENT PRELIMINARY REPORT

Report No:-------------------------

Date:------------------/------------------/ 200

Reporting Department / Site: --------------------

Accident / Incident type: (Check one or more boxes)

Injurious Incident
Property Damage
Fire / Explosion
Environmental Accident / Incident
Was anyone injured?

Yes
Name of Injured Persons

Time:------------------AM / PM

Location of accidents / incident:----------------------------------------------------- Occupational Illness

Near miss

No
Company

Did He/She attend clinic?

Description of Accident ./ Incident: (Attach Sketch/Photographs where necessary)

Cause of Injury:
Machinery / Plant
Hot Substances
Transport
Hazardous substances
Electricity
Slips / Tips / Fails
Fire Explosions
Striking against objects
Radiation
Dust in eyes
No risk assessment was performed for
Actual activity leading to Accident / incident:
Using portable tools/equipment
Driving/piloting
Operating plant/machinery
Grinding
Assembling/dismantling
Welding/burning
Scaffolding
Cleaning
Climbing/Descending
Painting
Mechanical lifting
Working at Depth
Walking
Digging
Medical Details:
Part of body affected
Head
Ankle
Fatal
Arm
Back
Fractures
Leg
Wrist
Burns
Hand
Eyes
Electric Shock
Finger
Ears
Crushing
Neck
Lungs
Dislocations
Shoulder
Multiple
irradiation
Disposition:
Home
Own Doctor
Return to work

Accident / Incident Classification:

Fatality
LWC

Restricted

Objects failing
Handling goods or articles
Falls from height over 2 m
Hand Tools
Others, specify

Handling hazardous materials/substances

Breaking connections
Loading / unloading
Draining / flushing
Working at height
Manual handling
Others, specify:

Nature of injury
Concussion
Ingestion
Foreign Bodies
Puncture
Asphyxiation
Poisoning
Sprain / Strain

Others

Referred to hospital

Medical treatment

First Aid

Occ.illness

HSE01-1104

Actions taken to mitigate consequences and to prevent Re-occurrence (Actions to be reviewed through risk assessment prior
to implementation) :

HSE Coordinator

Name
:
Signature :

Department / Site Manager

Name
:
Signature :

PAGES

PAGE

ACCIDENT /INCIDENT INVESTIGATION RESULT SHEET

Incident Report No:-------------------------Discussed Immediate Causes:
Failure in Communication

Poor Housekeeping

Inadequate PPE

Failure to follow procedures/Risk

assessment
Improper manual handling

Substance abuse

Failure to use/heed warnings/safety devices

Failure to wear PPE

Faulty tools/equipment

Inadequate warnings/safety devices

Work environment

Inadequate misuse of tools or equipment

Insufficient time for task

Inadequate ventilation

Insufficient of equipment/personnel

Poor lighting

Others, specify:________________________

Investigation Findings:

Witnesses Name

Company

Signature

Date

Attachments: (e.g. HSE Reports, permits, training records, etc)

Root Causes:
Inadequate knowledge/skill/understanding?

Inadequate physical/mental capability

Stress

Inadequate planning/procedures

Negligence

Inadequate maintenance

Inadequate supervision

Inadequate motivation

Inadequate risk assessment

Inadequate tools and equipment

Inadequate scheduling of task

Fatigue/ Illness

Inadequate management support

Others, specify:

Remedial actions (actions to be reviewed through risk assessment prior to implementation )

Action to be taken

Action by

Target Date

completion Date

signature

Investigation Team:

HSE02-1104

Name

Company

Signature

Date

ACCIDENT/INCIDENT INVESTIGATION REPORT

A

GENERAL INFORMATION

Time
:

Date
:

ACCIDENT / INCIDENT DEFINITIONS

FA: Where a person sustains injury

SA: Disabling injury and occupational

LTA:

An accident causing injury so

that a person can not continue
normal duties the next day or shift

MA:

SI: A serious incident which under

MI: Minor incident which under slightly

causing immediate death or death

within 24 hours

Area
:Company: IEOC / Contractor

(encircle one)

illnesses subsequent death,permanent

disability or property damage or loss
over $10,000
Minor accident, first aid, non
disabling injury or property
loss or loss which does not exceed
$10,000

Reported by
Date reported
Time reported

slightly different circumstances

could have resulted in a fatal or
serious incident

different circumstances could have

resulted in a minor accident

Person
Contacted:
C

FULL DESCRIPTION OF ACCIDENT/INCIDENT INCLUDING LOSS OF PROCESS,

HYDROCARBON RELEASE, MATERIALS, DAMAGE TO PROPERTY, EQUIPMENT
(Attach pertinent information, if required, such as Doctors medical report,
copy of Contractors accident report, statement of witnesses etc.)

Head
Eye
Ear
Neck
E

Indicate main part of body affected (tick box)

Part of Body Injured:

Leg
Foot
Toe
Shoulder
Nature of Injury/Illness

Amputation
Fracture
Burn (electrical)
Shock (electric)

Chest
Abdomen
Hip
Multiple

Crush
Cut/abrasions
Burn/Scald
Other (specify)

Skin Infection
Splinter/FB
Dislocation

Sprain/Strain
Burn (chemical)
Infection
G

Indicate major operation in progress at the location of the incident (tick box)

Production
Drilling
Materials Handling
Transport

Maintenance
Domestic/Catering
Construction/Civils
Other (specify)

Improper motivation

Abuse/misuse
of equipment
I

Operating equipment
without authority
Making safety devices
inoperative
Using defective
equipment/tools
Horseplay
Poor housekeeping

ACTIVITY LEADING TO INCIDENT

Indicate actual activity leading to incident
(tick box)

Using portable tools

Manual lifting

Operating plant/machinery

Driving

Electrical work

Other (specify)

BASIC UNDERLYING CAUSES(S)

H
Lack of skill

Finger
Hand/wrist
Arm

(tick one or more boxes)

OPERATIONS

Digestive
Back/Spine
Respiratory
Other (specify)

Inadequate tools/
Equipment
Inadequate supervision
Inadequate
maintenance
Excess wear & tear

Inadequate
purchasing
specification
Inadequate work
procedures
Lack of knowledge

Breach of Security
Security Incident
Other (specify)

IMMEDIATE CAUSE(S) Actions & Conditions (tick box)

Failing to use PPE
Improper lifting
Improper loading
Servicing equipment
in service
Inadequate warning
System

Using equipment
improperly
Inadequate protective
equipment
Inadequate guards
or barriers
Failure to follow Security
Procedures

Defective tools,
equipment, materials
Inadequate ventilation
Congestion or area
restricted
Other (specify)

ACCIDENT / INCIDENT COSTING

A Estimated Injury Cost

B Estimated Property Loss/Damage/Environmental Cost

C Estimated Repair Cost

$
$

D Estimated Investigation Cost

E Estimated Plant Downtime

Total Incident Cost (A+B+C+D+E)
K

Name:

SKETCH / SITE PLAN

DEPARTMENT CORRECTIVE ACTION PROPOSAL (To be filled in by Supervisor initiating this form)

Date:

Signature:

M
Name:

MANAGEMENT REVIEW OF SUPERVISORS ACTION PLAN

(Comments by Supervisors Line Manager)
Date:

Signature:

Field HSE Supervisor

Name:

Date:

Signature:

CORRECTIVE ACTION APPROVAL

To be completed by the persons listed below. If any of the above comments are not agreed with,
it is recommended that they be discussed with the relevant person to agree necessary actions.

HSE Manager

Signature:

Date:

Division Manager

Signature:

Date:

General Manager

Signature:

Date:

ACCIDENT COST
Cost of wages paid for time lost by workers
in accident location.
Cost of damage to material or equipment.
Cost of wages paid for time lost by injured
person
Cost of learning period of new worker
Medical cost
Cost of time spent by management and
supervisors in investigation.

Incident formal Investigation Report

The following information shall be included in the formal
report :
1- Introduction
A- Purpose of the investigation
B- Scope of the investigation
C- Who are the investigators

2- Description of the incident

A- Where and when the incident occurred ?
B- Who and what were involved ?
C- What happened ?
* Sequence of events
* Extent of damage
* Accident type
* Source of energy or hazardous material

Incident formal Investigation Report

3- How was the incident investigation
approached ?
4- How was the evidences collected ?
5- Analysis of evidences to identify the :
A- Immediate causes
B- Basic causes
C- Root causes

Incident formal Investigation Report

6789-

Discussion of findings ,outcomes and conclusions

Incident recommendations
Follow up the required actions and solutions
Appendices :
A- Incident investigation form
B- Documentation
C- Analysis Results
D- Witnesses statements
10- Signatures for all those responsibility for the
investigation

Incidents Recording and Rates

A good record keeping system can be used to
evaluate the safety performance and help the
safety professional in the following ways:

Identify high rate sites, locations or activities

and problem areas so extra efforts can be made

in those area.
Create interest in safety among supervisions by
furnishing them with their activities accident
experience.

Incidents Recording and Rates

A copy of the original report for all Site

Incident Reports shall be kept on file in

the Shift/Site Managers office.
A copy of the Site Incident Report updated
to reflect the current status of
investigation, action and close out shall be
kept by the HSE department.

Incidents Recording and Rates

A copy of the original Site Incident Report shall

be passed to the Quality Manager for filing.

This copy shall be replaced by updated status
copies and at close out.
Summary data for the original incident together
with progress of investigation, actions,
preventive measures and close out shall be kept
in a Site Incident Database.

Incidents Recording and Rates

Incidents Recording and Rates include the
following items:

1.0
2.0
3.0
4.0
6.0

Uses of records.
Accident categories.
Record keeping.
Standard formulas for rates.
Accidents costs.

Forms Used for Recording

Incidents Recording and Rates

a.Total manpower and man hours worked
b. Total KM traveled .
c. Accident categories.
d. Repair or replacement cost due to
damage.

e. Safety Record Rates LTIF and S.

Accident / Incident Categories

Accident/Incident Categories

CAT I

Multiple Fatalities or
permanent Total
disabilities , damage in
excess of
500,000$(inclusive)

CAT III

CAT II

CAT IV

Major injuries or health effect

that result or may result
permanent partial disabilities
or lost work day cases,
damage more than 10,000 but
less than 100,000(inclusive)

Single fatality or
permanent Total
disability , damage more
than 100,000 but less
than 500,000$ (inclusive)

Minor injuries or health effect

that result or may result medical
treatment cases, first aid cases
and restricted work cases , near
miss , damage less than 10,000
(inclusive)

Incidents Recording and Rates

Standard formulas for rates.

Lost Time Injury Frequency (LTIF)

Severity Rate (S)
Incident Rate (IR)
Vehicle Accident Frequency Rate ( FAFR )

Incidents Recording and Rates

Lost Time Injury Frequency (LTIF).

LTIF is the number of lost time injuries

per million exposure hours during the
period.

This rate shall be calculated and shown

in the Yearly and Project Safety
Records.

Incidents Recording and Rates

Lost Time Injury Frequency (LTIF) is
calculated by the following formula:

LOST TIME INJURIES x 1,000,000

LTIF =
TOTAL MAN-HOURS WORKED

Incidents Recording and Rates

Severity Rate (S)

"S" is Man-Days lost per million man

hours worked during the period.

This rate shall be calculated and shown

in the Yearly and Project Safety Record.

Incidents Recording and Rates

Severity Rate (S) is calculated by the
following formula:
MAN DAYS LOST x 1,000,000
"S" =

TOTAL MAN-HOURS WORKED

PAGES 1 PAGE 1

YEARLY HSE RECORD

YEAR:
Project
No.
No.

Project Name

ENPPI
Man-hours
x 1000

Contractor/
S ubcontractor
Man-hours x
1000

Total
Mhrs x 1000

ENPPI KM
Traveled
x 1000

Contractor/
S ubcontractor
KM
Traveled x
1000

Total KM
Traveled
X 1000

Category

TOTAL
MAN
DAYS
LOS T

S everity

Lost
Damage
Time LTIF VAF
Cost
Injuries
In $ US

Remarks

1
2
3
4
5
6
7
8
9
10

11

TOTAL
LEGEND:(CATEGORIES)
CAT I :Multiple Fatalities or Permanent Total Disabilities (Include Third Parties), Damage in Excess $200,000 (Inclusive).
CAT II:Single Fatality or Permanent Total Disabilty, Damage more than $100,00 but less than $200,000 (Inclusive).
CAT III:Major Injuries or Health effects That Result or may Result in Permanent Partial Disabilitites, lost Work Day Cases, Damage more than $ 10,000 but less
than $10,000 (Inclusive).
CAT IV: Minor Injuries or Health effects That Result or may Result in Restricted Work Day Cases, Medical Treatment Cases, First Aid Cases, Near Miss Cases,
Damage Less than $10,000 (Inclusive).
LOST TIME INJURY FREQUENCY =LOST TIME INJURY X 1000.000
TOTAL MAN-HOURS WORKED
HSE CO-ORDINATOR:
NAME:
SIGNATURE:

TOTAL MAN DAYS LOST X 1000.000

TOTAL MAN-HOURS WORKED
HSE DEPARTMENT MANAGER:
NAME:
SEVERITY=

SIGNATURE:

Incidents Recording and Rates

Calculations for man-days lost for PPD
& PTD main days lost for PPD & PTD
shall be as follows:

Main days lost = % of Disability X 6000

% of disability shall be defined by
insurance authorities.

Incidents Recording and Rates

Incident Rate (IR).

The incident rate is the number of

injuries, illness or lost work days,

related to common exposure base of
100 full-time workers, and shall be
determined as follows:
Incident rate = ( N X 200,000 ) / THW

Incidents Recording and Rates

Where:
N = number of injuries and / or illness or lost
workdays.

THW = total hours worked by all employees

during calendar year.
200,000 = base for 100 full time equivalent
workers. (working 40 hours per week,
50 weeks per year).

Incidents Recording and Rates

Vehicle Accident Frequency rate
(VAFR) is calculated by the following
formula:

No. of vehicle accidents x 1,000,000

VAFR

=
TOTAL KM Traveled

Incidents Recording and Rates

Vehicle accidents are involving any vehicle
in motion under the following factor :
Fatality
Lost work day case
Rollover
Head on collision
Damage cost > $`1,000

Fatal Accidents Frequency Rate

Fatal Accidents Frequency Rate

One way of measuring risk is fatal

accidents frequency rate (FAFR).

This method was introduced by ICI and is
used extensively in chemical industry.
The criterion in (FAFR) is usually based on
the expected number of fatalities
occurring in (10)8 working hours.

Fatal Accidents Frequency Rate

It is the number of deaths resulting from

industrial injury in a group of 1000 men

during their working lives (40 years).
In order to calculate FAFR, we must know
the hazard rate, or the rate at which
dangerous conditions arise on a plant.
FAFR is based on the following
relationship:

Fatal Accidents Frequency Rate

8
(10)

N.H.T.P
FAFR = --------------------8760

Fatal Accidents Frequency Rate

Where :
N = No. of persons exposed to hazard.

H = Hazard rate (per year).

T = Time proportion that personnel are exposed
to the hazard.
P = Probability that exposure to the hazard
results in death.

Fatal Accidents Frequency Rate

For example;
If a job is manned by one person all the year.
The hazard rate occurs at a frequency of (10-3).
If this person is always exposed to the hazard.
If it was assumed that the person will be killed every
time the hazard occurs.

Then FAFR is obtained by:

FAFR = 1 X (1X10-3) X 1 X 1 X (108) / 8760
FAFR = 11.4

Fatal Accidents Frequency Rate

Questions:
calculate FAFR for the above situation if:
If the person is exposed to the hazard 60 %
of the time.
If the person has 50 % chance of being killed
as a result of the hazard.
If 15 people are exposed to the hazard.

Fatal Accidents Frequency Rate

For the UK chemical industries, FAFR is

about 4.0
For the USA chemical industries, FAFR is
5.0 also.
For France chemical industries, FAFR is
8.5.
The following table shows a comparison of
FAFR between different UK industries.

Fatal Accidents Frequency Rate

INDUSTRY
Chemical industry
Clothing and footwear
Motor car industry
Timber and furniture
Metal work and ship yards
Agriculture
Coal mining
Railways
Construction industry

FAFR
4.0
0.15
1.3
3.0
8.0
10.0
40.0
45.0
67.0

Fatal Accidents Frequency Rate

The basis of the specification, is that no

employee should be exposed to FAFR

greater than the best achieved over ten
years.
For example, 4.0 in the case of chemical
industry.
Resources should be made available to
reduce any risks which exceeds this figure.

Fatal Accidents Frequency Rate

The target risk in the design of new plants

is normally based on 1/10th of the existing

FAFR, or the figure of FAFR = 0.4 in the
case of chemical industry.
The table outlines the estimated rates of
fatalities of disease attributed to types of
chemical and physical exposures.

Incidents Recommendations
&
Corrective Actions

Incident Recommendations
The investigation should aim to match each root
cause with corresponding appropriate
recommendation.

The recommendations should be arranged

according to the priorities or classified as:

Most important.
Important.
Necessary.
Suggested.

Incident Recommendations
All recommendations should be in the

form of practical action items such as:

Divers should take more care..

Supervisors should ensure that.
The rules for. Should be followed.

Corrective Actions
To eliminate or minimize the potential
hazard, one or more of the following
should be applied:
1- Engineering Controls
2- Administrative Controls ( e.g
Preventive Maintenance , Medical
checks )
3- Personal Protective Equipment

Corrective Actions
1- Engineering Controls :

Engineering protection is divided into the

following:

a) Passive Protection
b) Detection & Alarm System
c) Extinguishing System

Corrective Actions
A) Passive Protection:

Safety Distance
Housekeeping
General Layout
Fire Proofing
Fire / Blast Walls

Corrective Actions
B) Detection & Alarm Systems:

Heat Detectors
Smoke Detectors
Flame Detectors
Gas Detectors
Fire & Gas Control Panel

Corrective Actions
C) Extinguishing System:

Portable Extinguishers (CO2, Dry,

Chemical).
Wheeled Extinguishers
Water Hydrants
water Hose Reels
Water Hose Rack Cabinets

Corrective Actions
Fixed Water Spray System
Fixed / Mobile Foam Extinguishing

System
Fixed Water Sprinkler System
Fixed Clean Agent Extinguishing System
Fixed / Mobile Water Monitors

Corrective Actions
Preventive Maintenance

Preventive maintenance has mainly six

elements, which can be grouped together

in one word:

FICTAL

Corrective Actions
where:
F= Feeling of equipment performance.
I = Inspection Periodically.
C= Cleaning.
T= Testing.
A= Adjustment.
L= Lubrication.

Corrective Actions
Medical Protection
Medical Protection is the routine check on
the employees from Health point of view,
in order to achieve the following:
Ensure good health for employees
Monitoring of health situation for different
jobs
Provide fast remedy for unhealthy
personnel

Corrective Actions
3- Personal Protective equipment
Personal protection includes:

a) Personal Safety Clothing Type

b) Fall Protection and Rescue Harnesses

Corrective Actions
A) Personal Safety Clothing Type:

Hand Protection
Head Protection
Foot Protection
Vision & Eye Protection
Hearing Protection
Breathing & Respiratory Protection

Corrective Actions
B) Fall Protection and Rescue Harnesses

Harnesses, belt, fall-arrest devices, shock

absorbers and fixed anchorage are
available both for fall protection and
rescue.