PETRONAS TECHNICAL STANDARDS

HEALTH, SAFETY AND ENVIRONMENT

GUIDELINE

INCIDENT CLASSIFICATION, INVESTIGATION AND REPORTING

PTS 60.0501

AUGUST 2010

2010 PETROLIAM NASIONAL BERHAD (PETRONAS) All rights reserved. No part of this document may be reproduced, stored in a retrieval system or transmitted in

any form or by any means (electronic, mechanical, photocopying, recording or otherwise) without the permission of the copyright owner.

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PREFACE

PETRONAS Technical Standards (PTS) publications reflect the views, at the time of publication, of PETRONAS OPUs/Divisions. They are based on the experience acquired during the involvement with the design, construction, operation and maintenance of processing units and facilities. Where appropriate they are based on, or reference is made to, national and international standards and codes of practice. The objective is to set the recommended standard for good technical practice to be applied by PETRONAS' OPUs in oil and gas production facilities, refineries, gas processing plants, chemical plants, marketing facilities or any other such facility, and thereby to achieve maximum technical and economic benefit from standardization. The information set forth in these publications is provided to users for their consideration and decision to implement. This is of particular importance where PTS may not cover every requirement or diversity of condition at each locality. The system of PTS is expected to be sufficiently flexible to allow individual operating units to adapt the information set forth in PTS to their own environment and requirements. When Contractors or Manufacturers/Suppliers use PTS they shall be solely responsible for the quality of work and the attainment of the required design and engineering standards. In particular, for those requirements not specifically covered, it is expected of them to follow those design and engineering practices which will achieve the same level of integrity as reflected in the PTS. If in doubt, the Contractor or Manufacturer/Supplier shall, without detracting from his own responsibility, consult the owner. The right to use PTS rests with three categories of users:

1) PETRONAS and its affiliates. 2) Other parties who are authorized to use PTS subject to appropriate contractual

arrangements. 3) Contractors/subcontractors and Manufacturers/Suppliers under a contract with users

referred to under 1) and 2) which requires that tenders for projects, materials supplied or - generally - work performed on behalf of the said users comply with the relevant standards.

Subject to any particular terms and conditions as may be set forth in specific agreements with users, PETRONAS disclaims any liability of whatsoever nature for any damage (including injury or death) suffered by any company or person whomsoever as a result of or in connection with the use, application or implementation of any PTS, combination of PTS or any part thereof. The benefit of this disclaimer shall inure in all respects to PETRONAS and/or any company affiliated to PETRONAS that may issue PTS or require the use of PTS. Without prejudice to any specific terms in respect of confidentiality under relevant contractual arrangements, PTS shall not, without the prior written consent of PETRONAS, be disclosed by users to any company or person whomsoever and the PTS shall be used exclusively for the purpose they have been provided to the user. They shall be returned after use, including any copies which shall only be made by users with the express prior written consent of PETRONAS. The copyright of PTS vests in PETRONAS. Users shall arrange for PTS to be held in safe custody and PETRONAS may at any time require information satisfactory to PETRONAS in order to ascertain how users implement this requirement.

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Acknowledgement

This document was jointly prepared with contribution from the following persons and their respective organizations.

1. Sulo Belawan (Advisor) GHSED 2. Sazali Abu Kassim (Lead) GHSED 3. Busari Jabar GHSED 4. W Idrus W Sabli GHSED 5. M Zainudin M Zain GHSED 6. M Jasbir Khan Abdullah GHSED 7. M Farizuddin Anwar Mansor GHSED 8. Ibrahim Hamid MLNG 9. A Hisham Mohamad PDB 10. Ozair Saidin PGB 11. Roselan Mohamad PGB 12. Ahmad Tarmizi Jaafar PCSB 13. Rosnan Hamzah PCSB 14. M Hadzir M Said PPMSB 15. Chee Tze Chian MISC 16. Zukri Zainon CSD 17. M Hazman Hamzah CSD 18. Azharin Ahmad CSD

.

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TABLE OF CONTENTS

1.0 INTRODUCTION .................................................................................................................. 7

1.1 Objectives .................................................................................................................. 8

1.2 Structure of the Guide ............................................................................................... 9

1.3 Written Policy and Procedures ................................................................................. 9

2.0 SCOPE AND APPLICATIONS ............................................................................................ 11

2.1 Reporting Company ................................................................................................ 11

2.2 References ............................................................................................................... 11

3.0 DEFINITIONS ..................................................................................................................... 11

3.1 Types and Categorization of Incidents ................................................................... 11 3.1.1 Reportable Incident ...................................................................................... 11 3.1.2 Recordable Incident ..................................................................................... 12

4.0 IMMEDIATE ACTION AND NOTIFICATION ....................................................................... 12

4.1 Online Incident Notification and Reporting ............................................................ 12

4.2 Immediate Action at Location ................................................................................. 12

4.3 Notification From Incident Location ....................................................................... 12

4.4 Initial Notification to the Group ............................................................................... 13

4.5 Notification and Reporting to Authorities............................................................... 13

4.6 Submission of HSE Alert ......................................................................................... 14

5.0 THE INVESTIGATION ........................................................................................................ 14

5.1 General Principles and Requirements .................................................................... 14

5.2 The Investigation Process ....................................................................................... 14 5.2.1 Notification ................................................................................................... 14 5.2.2 Immediate Corrective Actions ..................................................................... 15

5.3 Analysis of Investigation Findings ......................................................................... 18 5.3.1 Purpose ........................................................................................................ 18 5.3.2 Involvement of People ................................................................................. 18 5.3.3 Underlying Causes ....................................................................................... 19 5.3.4 Recommendations ....................................................................................... 19 5.3.5 Consequence Management ......................................................................... 20

5.4 The Investigation Report ......................................................................................... 20

6.0 FOLLOW-UP ...................................................................................................................... 20

6.1 Communication of Lesson Learnt .......................................................................... 20

6.2 Implementation of Recommendations .................................................................... 21

6.3 Monitoring of Implementation ................................................................................. 21

6.4 Monthly Incidents Reporting ................................................................................... 21

7.0 INCIDENT ANALYSIS AND REPORTING .......................................................................... 22

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7.1 Completion of Data Recording and Submission of KPIs ....................................... 22

7.2 Submission of Report and Performing of Statistical Analysis .............................. 22

APPENDIX 1: DEFINITIONS AND EXPLANATION OF TERMS ...................................................... 23

APPENDIX 2: EXAMPLES AND INTERPRETATIONS ................................................................... 28

APPENDIX 3: INCIDENT CLASSIFICATION GUIDING PRINCIPLES, WORK RELATED AND EXPOSURE HOURS EXAMPLES ................................................................................................. 37

APPENDIX 4: MEDICAL TREATMENT CASES AND FIRST AID CASES ...................................... 40

APPENDIX 5: CLASSIFICATION OF OCCUPATIONAL ILLNESSES ............................................. 41

APPENDIX 6: INCIDENT CLASSIFICATION CRITERIA ................................................................. 42

APPENDIX 7: INCIDENT INITIAL NOTIFICATION .......................................................................... 45

APPENDIX 8: INCIDENT DIRECT CAUSE CLASSIFICATIONS ..................................................... 47

APPENDIX 9: MONTHLY REPORTING .......................................................................................... 50

APPENDIX 10: HSE ALERT FORM ................................................................................................ 51

APPENDIX 11: THE INVESTIGATION PROCESS .......................................................................... 52

APPENDIX 12: INCIDENT INVESTIGATION TREES ...................................................................... 62

APPENDIX 13: BASIC RISK FACTOR (BRF) DEFINITIONS .......................................................... 66

APPENDIX 14: INCIDENT INVESTIGATION REPORTS & PRESENTATION MATERIAL FORMAT ................................................................................................................................... 69

APPENDIX 15: INVESTIGATION OF NON ACCIDENTAL DEATH ................................................. 76

APPENDIX 16: SPECIAL SITUATIONS .......................................................................................... 77

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1.0 INTRODUCTION

Monitoring is an essential part of a systematic approach to HSE Management. This document provides guidance on the reporting of incidents, in order to be able to set targets for improvement and measure, appraise and report performance in pursuance of the goal to protect the environment, cause no harm to people, and protect asset.

This document is a result of combining two PTS documents namely:

PTS 60.0504 Incident Classification and Reporting (Guideline) Rev1 June 2006 PTS 60.0501 Incident Investigation (Guideline) Rev 1 June 2006,

and will carry the number PTS 60.0501 This document defines which incidents are to be reported to the PETRONAS Group Service Companies and authorities and when. It also provides guidance on internal reporting within OPU/JV/HCU companies, the investigation, and the documentation.

The guiding principles for incident reporting are that:

management controls should be in place for activities and operations having the

potential for incidents with a significant impact on the company incidents in such activities and operations are reported and included in the statistics

as a means of measuring the effectiveness of these management controls

Significant impact in this context refers to incidents with a consequence rating 3 to 5 in the Incident Classification Criteria Matrix.

It should be recognised that guidance on incident reporting is not, and cannot be, definitive for all situations as stakeholder perceptions, expectations and requirements vary from one country to another and change continuously.

The scope of this guidance is the classification and reporting of incidents resulting in injury or illness and/or damage (loss) to assets, the environment, reputation or security. New requirements on incident notification and reporting are added to improve on the categorization and analysis.

This document also provides guidelines on procedures for effective incident investigation and analysis.

There has been a tendency in incident investigation to address only specific occurrences which had actual outcomes and/or large consequences. The new approach presented in this guide puts emphasis on those incidents with the potential for serious injury, illness, damage or loss. Every incident should be investigated, although the seniority of investigators and the degree of detail of the investigation may vary and should depend on the actual and potential consequences of the incident. The document explains the level of investigations to be conducted internally within OPU/JV/HCUs and by PETRONAS Group HSE Division.

The primary purpose of incident investigation is to prevent recurrence of similar incidents by identifying deficiencies and recommending remedial actions. Follow-up should ensure that those actions are implemented. Statistical analysis of the results of incident reports can enhance the learning effect of each individual case by deriving trends. These can be used to identify and correct Health, Safety and Environmental (HSE) management weaknesses, as well as activity and hardware deficiencies in a Company's operations.

Studies have shown that incidents can have many causal factors and that underlying causes often exist away from the site of the incident. Proper identification of such causes requires timely and methodical investigation, going beyond the immediate evidence and looking for underlying conditions which may cause future incidents. Incident investigation should

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therefore be seen as a means to identify not only immediate causes leading to, but also failures / omissions in the management of the operation.

Management must support, be involved in investigations and prepared to act on investigation findings.

Lessons learned from incidents that are potentially of benefit to others should be communicated throughout the Company and within PETRONAS Group. Consideration should be given to communicate such lessons to other interested parties as appropriate. OPU/JV/HCUs and PETRONAS Group HSE Division are required to conduct periodical analysis of the incidents so that common issues within the OPU/JV/HCUs and/or Group can be rectified immediately.

1.1 Objectives

The objectives of this Guide are:

to provide a consistent requirements for OPU/JV/HCUs to classify and report incidents. to provide line managers, HSE advisors and contractor managers with a consistent

approach to incident investigation in order to achieve a high quality of reporting and analysis,

to explain the incident investigation process and the relationship between the available

techniques and methodologies for analysis and recording, to provide a basis for developing Company specific investigation procedures and

guidelines.

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1.2 Structure of the Guide

The main text of the Guide describes all the steps to be taken after an Incident has occurred. These are summarised in Figure 1. The incident notification and reporting timeline is summarized in Table 1.

Further details of the investigation process, techniques and methodologies, as relevant for the investigator or investigation team are presented in Appendix 11, 12 and 14. The Basic Risk Factor definitions are given in Appendix 13. Special investigations are given in Appendix 15 and 16. A list of definitions is given in Section 3 and further described in Appendix 1. The examples, classifications and reporting requirements are described in Appendix 2 to Appendix 10.

1.3 Written Policy and Procedures

An essential requirement for management of HSE is to have a written policy and procedures for incident investigation. These should be available to all employees and should require reporting, recording and investigation of all incidents which result in the following:

Work Injuries Occupational Illnesses Environmental Damage Property Damage Near Misses Security Breach

The procedure should specify the actions required at each stage in the investigation process and indicate the action parties, routing of communications and reports, and related deadlines. The procedures should be supplemented by guidelines on a number of issues, including the following:

classification and reporting preservation of evidence including condition and position of equipment, supervisory

instructions, work permits, recording charts, etc. formation of investigation teams assessment of incident potential HSE, drugs and alcohol policy evaluation of emergency response, rescue activities and damage control measures training in incident investigation awareness that reports may be required by third parties such as national authorities,

legal bodies, etc.

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Figure 1: Incident Classification, Investigation and Reporting Flow Chart

Table 1: Incident Notification and Reporting Timeline Summary Required Documentation from OPU Duration To Who Incident Notification (Minor: Rating 1 & 2) Within 24 hours after incident

OPU/JV/HCU internal management

Authority (if required) Incident Notification (Minor: Rating 3)

Within 24 hours after incident

COMCEN Head GHSED Respective VP OPU/JV/HCU internal

management Authority

Incident Notification (Major: Rating 4 & 5)

Within 1 hour after incident

All of the above Presidents Office EVPs Office Country Manager VP Legal SGM Corporate Services

(Corporate Affair) HSE Alert (Major Incident) Within 2 days after incident

OPU to GHSED. GHSED to disseminate to other OPUs/JVs/HCUs

Lesson Learnt (Major Incident) 1 week after completion of incident investigation

OPU to GHSED. GHSED to disseminate to other OPUs/JVs/HCUs

Final Investigation Report (Major Incident

1 month after completion of incident investigation

OPU to GHSED

Follow-Up Report (Fatal Incident) 1 year after the incident

OPU to GHSED

Monthly Incident (Summary) Reporting By 10

th day of each month OPU to GHSED

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SCOPE AND APPLICATIONS

2.1 Reporting Company

This document applies to those Companies/Joint Ventures/Holding Company Units where the PETRONAS has full authority to introduce and implement:

PTS 60.0101 Group HSE Management Systems Manual.

It also applies to those Companies/Joint Ventures/Holding Company Units which have agreed to report performance data to the Group.

These organisations are subsequently referred to as OPU/JV/HCU.

Individual queries about the application of this guide should be addressed to the relevant Business Organisation.

External HSE Reports will draw on data reported by OPU/JV/HCUs under this guidance and may be subjected to independent verification. For fatalities, in line with the practice adopted by other major oil companies, data given in external reports will usually only include OPU/JV/HCU and Contractor employees and not third parties. 2.2 References

This document makes some references to other documents such as: PTS 60.0112 Group Contingency Planning Standard 2008 PTS 60.0503 Tripod-Beta The Analytical Tool (Guideline) Rev1 June 2006

2.0 DEFINITIONS

3.1 Types and Categorization of Incidents

All incidents will be classified either as Reportable or Recordable. The major difference between these two categories is the element of span of control. Reportable Incident is one where management has the influence to put controls in place, whereas Recordable Incident is one where management has no influence over the controls that are put in place. The definitions for Reportable and Recordable Incidents are as follows (and further explained in Appendix 3): 3.1.1 Reportable Incident

A Reportable Incident is one that has caused injury to personnel/contractor/third party and/or damage to company property and/or pollution to environment and hence is required to be reported to the Group. The incident is included in companys statistics. The incident involves the following criteria:

i) Work-related activities carried out by company/contractor/third party personnel on

company premise and/or outside company premise, where exposure hours are accumulated, and /or;

ii) Span of Control. The company has full controlling influence to implement controls at location and monitor effectiveness, and/or;

iii) Time of incident. The incident occurs during working hours including lunch hours, overtime and traveling, and/or;

iv) Non-work related activities but inside company premise which has caused injury to

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personnel/contractor/third party or damage to property due to negligence, error or omission on the part of company.

3.1.2 Recordable Incident Recordable Incident is one where both the managements span of control and exposure hours accumulation are missing. The incident occurs not under the control of the company or its contractor while undertaking work-related activities. It is also incident of non-work related activities either inside or outside company premise which cause injury or damage to property but not due to negligence, error or omission on the part of company or personnel. The incident is not included in companys statistics.

The above definitions and other definitions can be found in Appendix 1 and the examples are given in Appendix 2. In addition to classifying each incident either as Reportable or Recordable, each incident should also be determined its Incident Direct Cause which is defined as an event or failure that led directly to the incident, without any additional intervening action or failure. The list of Incident Direct Cause is given in Appendix 8.

3.0 IMMEDIATE ACTION AND NOTIFICATION

4.1 Online Incident Notification and Reporting

Under PETRONAS iHSE database, there is a module on Incident Notification and Investigation System for online notification and submission of investigation reports. OPU/JV/HCU shall utilize the iHSE database to notify incident, create HSE Alert, capture investigation reports and create Lessons Learnt on incidents.

4.2 Immediate Action at Location

When an incident occurs the first action to be taken is to prevent further injury and arrange for any necessary medical treatment as well as taking measures to prevent the situation from escalating and causing further damage. Where possible, the site should be left unchanged until the investigation team has inspected it. Where this is not possible, photographs should be taken or sketches be made of the scene.

A preliminary assessment of the incident should be made to identify the extent of injury or damage, and any potential for escalation.

4.3 Notification From Incident Location

After arranging any necessary first aid and medical treatment and taking measures to prevent consequential losses and injuries, notification from the location of an incident is made in order to:

advise operations control (so that adjustment can be made to the plan of operations)

facilitate notification to other parties as required

initiate the investigation process.

Notification should be made via the senior person at the location or plant. Notification should be routed to the line function and to other departments from which assistance is sought and also to the HSE organisation. Routing should be specified in the Company's Incident Investigation Procedures. The notification should contain details of:

time, place, nature and direct cause of the Incident

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Classification of reportable or recordable incident

persons injured/equipment damaged

nature of injury/damage and estimate of severity (which rating in the Incident Classification Criteria Matrix)

immediate corrective action being taken

assistance required

operation in progress at the time.

The notification report should be factual and avoid hearsay, assumptions and preliminary conclusions. If the notification is made verbally via mobile phones, it should be followed up by a written email, faxed or telexed confirmation.

Operating companies should set stringent, fast, but achievable deadlines for notification to allow prompt initiation of the investigation process. All incidents should be communicated internally within 24 hours or other practical time.

4.4 Initial Notification to the Group

Rating 3 to Rating 5 incidents as per Incident Classification Matrix (Appendix 6) are regarded as Major Incidents and the Initial Notification should be reported immediately as per the guidelines in Appendix 7. Rating 3 incidents should be reported within 24 hours, whereas Rating 4 and 5 incidents should be reported within 1 hour to the relevant Group Services by using the standard form as given in Appendix 7. Notwithstanding of the above, any incidents that activate Tier 2 and Tier 3 of Emergency Response should be reported within 1 hour. The relevant units in the Group to be notified are:

- President Office - Business Head (Executive Vice President) - Respective Vice President - Country Manager for International Operation - Head, Group HSE Division - VP Legal - Senior General Manager Corporate Services / Corporate Affairs - COMCEN

In assigning the rating or severity of the incident for the purpose of the above initial

notification, Group HSE Division should be consulted. When there is incident that requires Initial Notification, the OPU/JV/HCUs should submit the notification to COMCEN and Business Head. COMCEN shall take the responsibility to notify the other relevant parties immediately. The responsibility for reporting incidents lies with the Company accumulating the exposure hours. In the case that hours are not accumulated e.g. for third parties and environmental incidents, the Company employing the personnel involved, or responsible for operating the equipment or facilities involved is responsible for reporting. 4.5 Notification and Reporting to Authorities

There may be a requirement for local or national authorities to be notified of all incidents in certain categories (e.g. in Malaysia, fatalities will involve both the local Police and Department of Occupational Safety and Health (DOSH), occupational illnesses and those accidents involving lifting appliances, pressure vessels requires notification to DOSH or motor vehicles to the local Police, and any environmental incident to Department of Environment).

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4.6 Submission of HSE Alert

The HSE Alert of all incidents of Rating 3 to 5 should be prepared by OPU/JV/HCUs and submitted to Group HSE Division by using the form in Appendix 10. The submission should be made within 2 days after the incident. Group HSE Division should review the submission, assign a Reference Number and disseminate the HSE Alert to other OPU/JV/HCUs. The requirements for classifying, notifying, recording, reporting, initiating investigation and conducting analysis are defined and included in the Group iHSE under Incident Investigation and Reporting Module.

5.0 THE INVESTIGATION

5.1 General Principles and Requirements 5.1.1 All incidents which fall under the scope of this PTS shall be investigated.

(Note: To ensure this is achievable, it is important that incident notification and reporting requirements as specified in Section 4 are fully complied with)

5.1.2 Investigations should be carried out as soon as possible after the accident. As the quality of evidence can deteriorate rapidly with time, any delayed investigations are usually not as conclusive as those performed with dispatch.

5.1.3 The purposes of accident investigation should be aimed towards identification of the root causes of accidents so that actions can be taken to prevent recurrence. Both actual and potential impacts should be identified. It may reveal the deficiency in HSE Management.

5.1.4 The responsibility for carrying out incident investigation lies with the owner of the asset or operations involved in the incident.

5.2 The Investigation Process

5.2.1 Notification

a. After arranging first aid and medical treatment and taking measures to

prevent consequential losses and injuries, notification from the location of an accident shall be made. To ensure sufficient information is available for incident investigation planning purposes, incident notification should contain details on:

operation in progress at the time time, place and nature of accident persons injured/equipment damaged nature of injury/damage and estimate of severity immediate corrective action being taken assistance required.

b. Notification of incident within the OPU/JV/HCU should be made by the senior

supervisor at the location or plant; notification of road transport accidents away from company premises should be made by the driver involved. To ensure incident investigation can be initiated timely, OPU/JV/HCU shall establish effective routes and means of communication.

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c. To initiate the investigation for Major Incident, Terms of Reference shall be

established.

5.2.2 Immediate Corrective Actions

Corrective actions shall be carried out to make the incident site safe and does not endanger other personnel or the plant. However as much as possible, OPU/JV/HCUs should keep the site 'as is' until at least a preliminary investigation has taken place.

It may be necessary to clear the area or rectify problem in order to minimize the consequence, eliminate the hazards or facilitate emergency response operations. In such cases, photographs of the sites should be taken and relevant evidences preserved.

Local legislation may prescribe that for certain classes of accident, e.g. fatality or motor vehicle accident, nothing may be moved without prior permission from authorized persons.

5.2.3 Investigation Team

a. General

The size and composition of an investigation team should depend on factors such as:

the extent of actual or potential injury or damage the potential for repetition the departments involved requirements for specialist knowledge legal requirements

In this context the investigation of a Near Miss with serious incident potential may demand more resources and expertise than some incidents which have actually resulted in damage or injury. For the minor incidents, collection and analysis of repetitive cases provide measures of improvement.

Investigation must be done by trained team members, or at least trained team leader, by using proven tools, methodology and procedures. Independencies of investigation should be observed. This can be done by having the Investigation Team led by unaffected department. Multi-expertise team members are recommended, for example for OH cases, OH Doctor may become one of the investigation team members.

Following the concept of line responsibility for safety, the line should take the lead in incident investigation.

When the Terms of Reference is established, the Investigation Team should adhere to the document.

b. Contractor Incidents The general principles and requirements on incident investigation as specified in Section 5.1 is also applicable for all incidents involving contractors operations or personnel which occur on PETRONAS premises or involves PETRONAS property or interests.

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c. Investigation by Local or National Authorities In the event that local authorities take over responsibility for the investigation, OPU/JV/HCU should nominate a focal point to liaise with the authorities and to assist them in assembling the information they require. Notwithstanding the involvement of the authorities, OPU/JV/HCU should carry out their own investigation into the accident. Where relevant to a proper understanding of the accident, the Company should endeavour to obtain from the authorities any evidence, such as copies of (police) reports. For detail, please refer to Appendix II Section 2.0

5.2.4 Facts Finding Process

a. General

In carrying out investigation, the team should collect as many facts as possible which may help understanding of the incident and the events surrounding it. The main sources of information are:

observations at the scene of the incident interviews written instructions and procedures records reports of specialist investigations

It may sometimes be appropriate to obtain background information before visiting the incident site. For example:

general procedures for the type of operation involved records of instructions/briefings given on the particular job being investigated location plans command structure and persons involved.

Checklists may be used in the early stages if the investigation to keep the full range of enquiry in mind. When checklists are used, their limitations should be clearly understood.

b. Site Inspection

Important evidence can be gained from observations made at the scene of the incident, particularly if equipment remains as it was at the time of the incident. Witnesses' statements can usually be better understood and verified if discussed at site.

Photographs and/or video film may be taken during site visit. In the absence of photographs or films, sketches or graphical illustrations of the site layout or equipment could be made. While photographs and diagrams can be used in the incident analysis and/or as attachments in the investigation report, video films may be used later for HSE communication or training purposes.

During site visit, the investigators should look for any conditions in the immediate environment which could have contributed to the incident. Examples of items to check include:

the position of all equipment in relation to other equipment/facilities the position of valves, spades, set points, recorders, override switches etc.

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the condition of the load-bearing surface accessibility/evidence of congestion illumination of the location/site state of housekeeping the condition of all equipment/facilities presence (absence) of warning signs/notices effects of weather presence of witnesses evidence of spills or release odours, discolouration presence of unauthorised people - evidence of excessive forces

c. Interview

Interview shall be carried out at earliest time possible in order to be able to capture initial knowledge of each witness before lapse of times.

The following should be consider in planning for an interview

Prioritize the persons to be interviewed, starting from the victim(s) or personnel directly involved in the incident and followed by witnesses and other personnel such as the work supervisors, colleagues and management personnel.

Appropriate interviewer should be selected taking into consideration the subject matters to be checked, areas of expertise, level in the organizational hierarchy and personality of the individual

Proper scheduling interviews to ensure availability of interviewer

Specific checklists may be developed to facilitate in the interviewing process

The following Guidelines should be used when conducting an interview

Interview should be carried out at appropriate and conducive location, preferably in the interviewees room, work place or at the incident site. If the interviewee is the injured person, it may be necessary to interview him at the hospital or at his home if the interviewee is undergoing medical treatment at the hospital or taking rest the home.

Interviews should be carried out individually so that interviewees are not influenced by each other

Witnesses should be asked to go step-by-step through the events surrounding the accident, describing both their own actions and the actions of others. In order to ensure that all the facts are uncovered, the open and broad questions of "what?, why?, when?, how?, where? and who?" should be utilised.

The value of a witness's statement can be greatly influenced by the style i.e. personality/character, language, job position of the interviewer, whose main task is to listen to the witness's story and not to influence him/her by making comments or asking leading questions.

Great care should be taken not to make an interviewee feels intimidated by too many interviewers

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Maintain confidentiality of the interviews

At the end of an interview the discussion should be summarized to make sure that no misunderstandings exist. Any anomalies in the statement or conflict with other evidence should be discussed, the interviewee being invited to clarify points as necessary.

In particular it should be noted that the statements made by different witnesses may conflict, and supporting evidence may be needed.

d. Documents Review

Relevant documents should be reviewed as they could serve as evidences or could provide information which may lead to identification of directs or underlying causes of the incident. Such documents may be available in the form records such as "as-built" drawings, instrument and tachograph records, print-outs, log sheets/books, maintenance records, work permits, load and time sheets.

Written instructions and procedures may provide information to the investigation team on work processes and parties involved in the activities.

The investigation should try to establish the extent to which written procedures and instructions were understood and acted upon, as these can indicate the effectiveness of training and supervision.

e. Incident Investigation Trees

During the fact finding stage, incident investigation tree may be constructed to show the connections between the various possible events and conditions leading to the incident. Appropriate incident investigation diagram based on established incident causation model e.g. fault tree diagram, cause and effect diagram etc may be used.

5.3 Analysis of Investigation Findings 5.3.1 Purpose

The purpose of analysing is to establish the sequences of critical events and the underlying causes of the incident and of its consequences. Note: Analysis of a group of incidents can highlight patterns or trends in types of incidents or incident causes, so that safety efforts can be focussed on recurring causal factors or recognisable hazard areas.

5.3.2 Involvement of People

It is almost inevitable that the actions or omissions of people are found among the causal factors. A common reaction to this is for the investigation process to lean towards a 'blame' culture, typified by punishment featuring prominently in the recommended actions. The blame culture acts against the prime objectives of investigation by inhibiting the frankness which is necessary during fact finding. Errors of professional judgement should be viewed in the context of the discretion and initiative that is normally expected. An organisation must be prepared to question its own philosophies, standards and management style to ensure that it has not created a culture which invites or conditions its personnel to cut comers or take chances.

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5.3.3 Underlying Causes

The investigation of incidents beyond the immediate and most obvious causes calls for a broad approach. During the analysis it will be necessary to look in more detail at areas such as:

company policy managerial practices operating philosophies and procedures engineering design equipment selection work planning job descriptions and responsibilities organisational relationships control systems qualifications and experience criteria training methods working/duty hours policies and practices safety auditing contract conditions and controls maintenance procedures and records testing methods and records methods of instruction and communication operator perceptions.

Existing policies and procedures may have had elements or omissions which, combined with other causal factors, have contributed to the incident. Effective investigation needs to seek the 'causes behind the causes' (i.e. defects in the systems for planning, controlling and executing the work). This can involve selfcriticism, and/or the challenging of systems, procedures, policies or even cultural norms which have been accepted hitherto. Where deficiencies are highlighted, the analysis process should look into why they were not detected and corrected before the incident (i.e. shortcomings in management). Investigations can open up a wide range of causal factors, many of them linked together in their contribution to a particular incident. Even if all causes cannot be addressed at once, removal of some critical links will significantly reduce the probability of such incidents recurring. Systematic investigation should ensure that possible causes are considered in both the range and depth appropriate to the incident. In addition to the causes of the initial event, causes of consequential injury or damage should be examined, as these may also highlight inherent deficiencies. Any assumptions made during the analysis should be clearly identified in the report, as they are open to challenge.

5.3.4 Recommendations The ultimate objective of the investigation process is to identify action to prevent recurrence. Not all causes can be completely eliminated, and some may be eliminated only at prohibitive cost. Some recommendations will therefore be aimed at reducing a risk to an acceptable level, while others will be aimed at improving protective systems to limit the consequences.

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All recommendations should be in the form of practical action items. They should identify the action party, so that effective follow-up can be achieved. Deadlines for action can be suggested for subsequent endorsement by the action party. Recommendations relating to procedures or the quality of supervision or training have the following advantages:

the solutions lie with the people in the incident environment they can usually be implemented quickly implementation can usually be achieved with little or no additional costs.

Modifications to facilities, additional equipment or other 'hardware' solutions are appropriate in many cases, but they can have disadvantages:

they may avoid more fundamental and difficult 'people' issues relating to management, supervision and training,

they are sometimes used as an attempt to buy a way out of a problem rather than to 'think' a way out,

they require funds, and therefore the onus for providing a solution is passed to someone else, i.e higher management,

they can take more time to implement, they may create other problems, e.g maintenance, or access.

When considering possible corrective actions the following factors should be borne in mind:

effectiveness, practicability,urgency/implementation time, permanency, extent or breadth of benefit. Where an investigation highlights deficiencies not related to the incident, a separate report and recommendations should be made.

Cases of extreme negligence or blatant disregard for established safe practices may indicate the need for disciplinary measures. At the review stage, the specific measures considered appropriate should be confirmed. If there are alternative recommendations, the preferred one should be indicated. In the event that a recommendation will take a long time to implement, interim measures should be suggested. To prevent a single factor (e.g. metallurgic testing) holding up the reporting, a recommendation could be to investigate further in that specific area. Group HSE Division should be consulted on any findings of the analysis and recommendations. 5.3.5 Consequence Management Incident investigation findings shall address elements of negligence or failure of individual(s) or party(ies) in discharging their roles and responsibilities which had contributed to the incident. Consequence management actions e.g. show cause letter or other appropriate disciplinary actions which have been or need to be taken shall be included in the investigation report.

5.4 The Investigation Report

The investigation report is a presentation of the findings and recommendations of the investigation team. The report should be in a standard format (see Appendix 14). Before distribution the investigation report should be reviewed at the appropriate management level, as a check on the completeness of the investigation and for endorsement of the recommended actions.

6.0 FOLLOW-UP

6.1 Communication of Lesson Learnt

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To maximise the lessons learnt, relevant findings and conclusions of incident investigations should be given as wide a distribution as practicable.

The lessons learnt of all incidents of Rating 3 to 5 should be prepared by OPU/JV/HCU and submitted to Group HSE Division within one week after the completion of Incident Investigation. Group HSE Division should review the submission, assign Reference Number and disseminate the lessons learnt to other OPU/JV/HCUs.

Discussions at, and feedback from, HSE meetings and team briefings should be used to maximise the benefits from the learning points of the incident investigation and help achieve the objective of preventing of similar incidents.

Learning points which may have a wider industry value may be exchanged with industry contacts, safety institutes, etc.

6.2 Implementation of Recommendations

Recommendations should be discussed on a formal basis with action parties for agreement on the action required and the time-schedule for implementation. This should be reviewed and endorsed by OPU/JV/HCU management.

6.3 Monitoring of Implementation

Much of the value of incident investigation will be lost if the implementation of agreed recommendations is not achieved. Where recommendations cannot be fully implemented immediately, a formal follow-up monitoring system is required to ensure that agreed actions are implemented and/or non-conformances are known to management and formally endorsed.

Hardware related items are normally easy to identify as having been completed, e.g. when the modification has been effected or when the new equipment has been received or installed. This is not always the case with items such as training, changes to procedures or supervision and particularly when action is described as "ongoing". A precise description of the action item is essential if it is to be effective.

It is suggested that a procedural action point is considered to have been completed when:

approved written instructions have been issued and circulated to all staff concerned when the changes in procedures have been monitored and found to be effective.

It will be necessary to set a deadline to ensure implementation of recommendations. The schedule for implementation should take both of these progresses into account.

Items involving training or changes in supervision should be handled in a way similar to procedures. The changes must be planned, circulated as necessary, and monitored until they are seen to have taken effect.

The quality of incident investigation and the effectiveness of the solutions implemented should be audited on a routine basis. If there are shortcomings they should be tackled by training programmes or other techniques.

Note: The Group reporting procedure for fatal accidents requires a follow-up report to be made one year after the accident, reviewing actions taken and assessing their results.

Details as per Appendix 11.

6.4 Monthly Incidents Reporting

Each OPU/JV/HCU should report the summary of incidents monthly to Group HSE Division

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for consolidation and reporting to higher management. The summary report should follow the form as per Appendix 9 and should be submitted to Group HSE Division by 10th day of each month. The same requirement should be reflected in the iHSE system.

7.0 INCIDENT ANALYSIS AND REPORTING

7.1 Completion of Data Recording and Submission of KPIs

After completing the investigation, the data in the initial notification and HSE Alert should be updated accordingly to the final findings from the investigation. This should be apparent when using iHSE system. The KPIs should be reported on monthly basis to Group HSE Division.

7.2 Submission of Report and Performing of Statistical Analysis

The current statistical analysis of incidents might have focused mainly on trend monitoring of injury and incident frequencies in terms of actual consequences. Identified trends were used to set future targets.

With the improved PTS and introduction of iHSE, the scope, range and quality of statistical analyses can be increased e.g. by incident classification and recording in terms of:

direct cause reportable and recordable incidents underlying causes or root causes (by use of the 11 Tripod General Failure Types /

Basic Risk Factors).

This analysis allows for better identification of the lessons learnt from individual incidents and improves the ability to identify and correct weaknesses in HSE management. In addition, it can also facilitate performance monitoring of individual units, contractors, etc.

Statistical analysis of incidents is only able to reflect what has happened and is therefore a reflection of past policies and their implementation. For statistical analysis to be meaningful a significant number of entries is required in order to be able to detect trends. As a company's safety performance improves, complete recording and analysis of all incidents becomes increasingly more important. In order to give flexibility for OPU/JV/HCU to conduct investigation, OPU/JV/HCU may use various investigation tools to complete their investigation. For MAJOR incidents, however, the use of Tripod Beta tool is very much encouraged and recommended. To ensure consistent analysis is conducted and common root causes are identified, the final investigation findings should be consistently reported by using the same 11 Tripod Basic Risk Factors for the categorization of the root causes. This is to ensure analysis is conducted of the same spectrum. If investigation tools other than Tripod Beta is used, the root causes need to be aligned to the 11 Tripod Basic Risk Factors.

The final investigation report for MAJOR incident should be submitted to Group HSE Division no later than 1 month after the completion of the investigation. If confidentiality is an issue, a summary report should be prepared and submitted within the same timeframe mentioned above. The summary report should contain the following: - Summary - Brief Introduction (describing the incident including type of incident, type of injury, phase of

operation or activity, cause of incident, and direct cause category) - Root Causes (in the forms of Tripod Beta BRF). - Conclusion and Recommendations - Lessons Learnt

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APPENDIX 1: DEFINITIONS AND EXPLANATION OF TERMS ACCIDENT An Accident is an Incident which has resulted in actual Injury or Illness and/or Damage (Loss) to Assets, the Environment or Third Party(ies).

CONTRACTOR Contractors include all parties working for the reporting OPU/JV/HCU either as a direct Contractor, or as a sub-contractor.

EMPLOYMENT

Employment means all work or activity performed in carrying out an assignment or request of a Reporting Company or Reportable Contractor, including related activities not specifically covered by the assignment or request.

Employment also includes activities, even outside working hours, where the Reporting Company has the Prevailing Influence. Under certain circumstances travel to and from work is also considered as being in the course of Employment.

EXPOSURE HOURS Exposure hours are the total number of hours worked including overtime and training but excluding leave, sickness and other absences. The exposure hours should be reported separately for OPU/JV/HCU and Contractor personnel. A meaningful assessment of incident data requires the number of exposure hours of work related activities of OPU/JV/HCU personnel and Contractors to be accumulated. Guidance on the number of exposure hours to be accumulated is given in Appendix 3. Contractor activities that are excluded by the OPU/JV/HCU for reporting - on the basis of risk considerations - shall not accumulate exposure hours. Time off-duty, even if this time is spent on OPU/JV/HCU premises, is not accumulated for the calculation of exposure hours although incidents during this time shall be included if they are the result of failure or absence of management controls. FATAL ACCIDENT RATE (FAR) The Fatal Accident Rate is the number of work-related Fatalities per 100 million exposure hours. FIRES AND EXPLOSIONS Normally taken to mean all fires that necessitated the use of a fire extinguisher or other extinguishing means, e.g. snuffing steam, shut off fuel or switch off electricity supply. Fires with no visible flames, e.g. oil soaked insulation, should also be included. All flammable explosions or overpressure explosions should be included, irrespective of the extent of containment.

FIRST AID CASE (FAC) Any one-time treatment and subsequent observation of minor scratches, cuts, burns, splinters, etc., which do not ordinarily require medical care by a physician. Such treatment and observation are considered First Aid even if provided by a physician or registered professional personnel. Examples of FACs are to be found in Appendix 4.

INCIDENT An Incident is an unplanned event or chain of events, which has, or could have caused injury or

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illness and/or damage (loss) to people, assets, the environment, reputation, or third party(ies). Any injury such as a cut, fracture, sprain, amputation etc, which results from a single instantaneous exposure. INCIDENT DIRECT CAUSE An event or failure that led directly to the incident, without any additional intervening action or failure.

LOST TIME INJURIES (LTIS) Lost Time Injuries are the sum of Fatalities, Permanent Total Disabilities and Lost Workday Cases but excluding Restricted Work Cases.

LOST TIME INJURY FREQUENCY (LTIF) The Lost Time Injury Frequency is the number of Lost Time Injuries per million exposure hours.

LOST WORKDAY CASE (LWC) A Lost Workday Case is any work-related Injury which renders the injured person temporarily unable to perform any Regular Job or Restricted Work on any day after the day on which the injury was received. In this case "any day" includes rest day, weekend day, scheduled holiday, public holiday or subsequent day after ceasing employment. A single incident can give rise to several Lost Workday Cases, depending on the number of people injured as a result of that incident.

MEDICAL TREATMENT CASE (MTC) A Medical Treatment Case is any work-related Injury that involves neither Lost Workdays nor Restricted Workdays but which requires treatment by, or under the specific order of, a physician or could be considered as being in the province of a physician. Medical Treatment does not include First Aid even if this is provided by a physician or registered professional personnel. Examples of MTCs are to be found in Appendix 4.

NEAR MISS A Near Miss is an Incident which potentially could have caused Injury or Occupational Illness and/or damage (loss) to people, assets, the environment or reputation, but which did not.

OCCUPATIONAL ILLNESS An Occupational Illness is any work-related abnormal condition or disorder, other than an Injury, which is mainly caused by exposure to environmental factors associated with the employment. It includes acute and chronic Illness or diseases which may be caused by inhalation, absorption, ingestion or direct contact. Whether a case involves a work-related Injury or an Occupational Illness is determined by the nature of the original event or exposure which caused the case, not by the resulting condition of the affected employee. An Injury results from a single event. Cases resulting from anything other than a single event are considered Occupational Illnesses. The basic difference between an Injury and Illness is the single event concept. If the event resulted from something that happened in one instant, it is an injury. If it is resulted from prolonged or multiple exposures to a hazardous substance or environmental factor, it is an Illness.

PERMANENT TOTAL DISABILITY Permanent Total Disability is any work-related Injury which permanently incapacitates an employee and results in termination of employment.

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OPU/JV/HCU PREMISES OPU/JV/HCU premises are: - those owned by the OPU/JV/HCU

- those rented by the OPU/JV/HCU

- Contractors premises which for a time period are fully dedicated to OPU/JV/HCU operations, and - any other site clearly identified with the brand e.g. retail forecourts under OPU/JV/HCU

management control. RECORDABLE INCIDENT Recordable Incident is one where both the managements span of control and exposure hours accumulation are missing. The incident occurs not under the control of the company or its contractor while undertaking work-related activities. It is also incident of non-work related activities either inside or outside company premise which cause injury or damage to property but not due to negligence, error or omission on the part of company or personnel. The incident is not included in companys statistics. This is further explained in Appendix 3. REGULAR JOB A Regular Job is one which has not been established to accommodate an injured employee. It should be an existing job or task within the OPU/JV/HCU or Contractors organisation which the injured person is deemed competent to perform.

REPORTABLE INCIDENT

A Reportable Incident is one that has caused injury to personnel/contractor/third party and/or damage to company property and/or pollution to environment and hence is required to be reported to the Group. The incident is included in companys statistics. The incident involves the following criteria:

i) Work-related activities carried out by company/contractor/third party personnel on company premise and/or outside company premise, where exposure hours are accumulated, and /or;

ii) Span of Control. The company has full controlling influence to implement controls at location and monitor effectiveness, and/or;

iii) Time of incident. The incident occurs during working hours including lunch hours, overtime and traveling, and/or;

iv) Non-work related activities but inside company premise which has caused injury to personnel/contractor/third party or damage to property due to negligence, error or omission on the part of company.

This is further explained in Appendix 3.

REPORTABLE WORK INJURY A Reportable Work Injury is any Work Injury which results in:

i) fatality

ii) permanent total disability

iii) permanent partial disability

iv) lost work days

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v) restricted work days

vi) medical treatment

Any injury which progresses from one category to a category higher on the above list shall be recorded in the higher category only.

RESTRICTED WORK CASE (RWC) A Restricted Work Case is any work-related Injury which results in a work assignment after the day the incident occurred that does not include all the normal duties of the person's Regular Job. The restricted work assignment must be meaningful and pre-established or a substantial part of a Regular Job.

ROAD TRAFFIC ACCIDENT An Incident which has involved a vehicle and which has resulted in Injury, Illness and/or damage (loss) to people, assets, the environment or the OPU/JV/HCUs reputation.

SECURITY INCIDENT

A Security Incident is one which involves purposeful or deliberate attempts to defraud, cheat or steal property or possessions of the Reporting Company or to willfully injure an employee of a Reporting Company or Reportable Contractor.

THIRD PARTIES Third Parties are persons or organisations which are not employed by or contracted to the Reporting OPU/JV/HCU or Contractor.

TOTAL REPORTABLE CASES (TRC) Total Reportable Cases are the sum of Fatalities, Permanent Total Disabilities, Permanent Partial Disabilities, Lost Workday Cases, Restricted Work Cases and Medical Treatment Cases.

TOTAL REPORTABLE CASE FREQUENCY (TRCF) The Total Reportable Case Frequency is the number of Total Reportable Cases per million Exposure Hours.

TOTAL REPORTABLE OCCUPATIONAL ILLNESS (TROI) Total Reportable Occupational Illnesses are the number of Occupational Illnesses. Any identified Occupational Illness known to the Company is to be included, even if no lost/restricted workdays are involved and/or no medical treatment is given. A single exposure can give rise to several Occupational Illness cases.

TOTAL REPORTABLE OCCUPATIONAL ILLNESS FREQUENCY (TROIF) The Total Reportable Occupational Illness Frequency is the number of Occupational Illnesses per million Exposure Hours.

A work-related Fatality is a death resulting from a work-related Injury or Occupational Illness, regardless of the time intervening between Injury/Illness and death.

WORK INJURY

A Work Injury is an injury or illness, regardless of severity, which arises from a single event (or a number of events close together in time) in the course of Employment.

In cases where this definition gives reasons for doubt, an injury should be treated as a Work Injury.

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Injuries in the course of Employment which are caused by willful acts are, in general, treated as Work Injuries.

Injuries caused by the deficiencies in equipment or management controls for which the Reporting Company is responsible are treated as Work Injuries, even when they occur outside working hours.

Occupational illnesses and death from natural causes are not considered as Work Injuries for the purpose of this Guide. WORK RELATED For the purpose of this document, the term, "Work-Related" is used to describe those activities for which management controls are, or should have been, in place. Incidents occurring during such activities are reportable and will be included in the statistics. In order to encourage consistency in the reporting practices of PETRONAS, as a minimum, the following activities are considered work-related as they are susceptible to incidents with significant impact for which management controls should be in place: all work by OPU/JV/HCU personnel; all work by Contractor personnel on OPU/JV/HCU premises, and all work by Contractor personnel on non-OPU/JV/HCU premises for which it is concluded on the

basis of risk considerations that Company and Contractor management controls are required. For OPU/JV/HCU personnel, "Work" includes attending courses, conferences and OPU/JV/HCU organised events, business travel, field visits, or any other activity or presence expected by the employer. For Contractor personnel, the same activities are included when they are executed under a contract on behalf of the OPU/JV/HCU. Contractor includes all sub-contracted personnel. Where it is impossible or inappropriate for the OPU/JV/HCU to seek to impose management control on Contractor exceptions may be justifiable. Examples may be found in areas where Contractor services are not dedicated to the company e.g.: manufacturing of components in a factory together with the manufacture of components for other

customers; construction at a Contractor's fabrication site shared by other customers; delivery of goods to company locations by a Contractor who is also employed for delivering goods

to other companies during the same journey, and customer collection of OPU/JV/HCU products, where the vehicle and drivers are under the control

of the customer. The OPU/JV/HCU should make a conscious, balanced and documented decision whether or not to maintain management controls and include incidents in the performance indicators.

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APPENDIX 2: EXAMPLES AND INTERPRETATIONS 1 TRANSPORTATION-RELATED INCIDENTS All work-related injuries and illnesses are to be reported and included in statistics. Please refer to PTS 60.2401 Land Transportation Safety Guiding Principles, Minimum Standards and Key Performance Indicators for the requirements of reporting transportation statistics. 1.1 TRANSPORTATION OF PERSONNEL Considered To Be Work-Related

Personnel travelling in OPU/JV/HCU-owned or arranged transport. Personnel travelling exclusively on OPU/JV/HCUs business who decided to use public or private transport instead of OPU/JV/HCU-owned or arranged transport. For example, travelling from their normal workplace or office to a temporary place of work such as fabrication site; or travelling from temporary accommodation e.g. base camp or transit place to a place of work. b) Not Considered To Be Work-Related

OPU/JV/HCU and Contractor personnel commuting between home and normal work place on other than OPU/JV/HCU arranged transport.

Non business-related travel in vehicles that are allocated to employees or Contractor

personnel for their unrestricted personal use. OPU/JV/HCU and Contractor personnel travelling (even at irregular hours) from their home to

a regular assembly point where they are collected in transport specially furnished by their employer.

Personnel deviating from a business trip for personal reasons provided this does not breach

OPU/JV/HCU procedures. Example 1: An employee has an OPU/JV/HCU vehicle for which he/she has unrestricted personal use. The employee is due to attend a business meeting some distance away on a Monday morning. The employee decides to leave on the Friday and break his journey by visiting friends. An incident occurs at that time. It is not work-related. Example 2: Another employee has to use a pool car for a similar business meeting but persuades the pool supervisor to breach OPU/JV/HCU procedures and release the car on the Friday so he/she can visit friends. If an incident occurs at that time it is work-related. Notes: Where an Incident occurs during travel in non OPU/JV/HCU arranged transport, and subsequent investigation shows that OPU/JV/HCU transport should have been provided (because, for example incidents during this activity could create a negative impact on the OPU/JV/HCU) then the incident should be considered work-related. Example 3: An employee has to travel from home to the local airport for a weekly shift at an interior location. If the roads are safe and transport by private vehicle is the norm, then this would be considered as commuting. However, given the same situation but the road is known to be dangerous e.g. as a result of many armed robberies, OPU/JV/HCU transport should be provided or arranged. If no OPU/JV/HCU transport is provided then the Incident involving private transport is considered work-related.

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Example 4: A ship crew member is travelling ashore by launch for an authorised recreational trip. The employer is expected to arrange safe transport. Therefore, if an Incident occurs, e.g. from a collision of the launch with another ship, any injuries would be considered to be work-related 1.2 TRANSPORTATION OF GOODS AND EQUIPMENT Considered to be work-related

Transportation of goods and equipment within OPU/JV/HCU managed locations. Transportation of goods and equipment on OPU/JV/HCU owned or contracted transport (e.g.

cars, vans, OPU/JV/HCU aircraft, etc.) Transportation of goods and equipment readily identifiable as related to the OPU/JV/HCU

operations. (e.g. seismic vehicles, land drilling rigs etc.) Not considered to be work related

Those transport activities which are not primarily dedicated to the supply of goods and equipment for the OPU/JV/HCU or its Contractors and which are not readily identifiable as related to OPU/JV/HCU or its Contractors and do not present a high risk to the Company (e.g. delivery of mail, use of road, air and sea freight, Contractors engaged on multi deliveries.)

1.3 TRANSPORTATION OF PRODUCT Considered to be work-related

All incidents which occur to OPU/JV/HCU employees, and to Contractors on OPU/JV/HCU premises or working under the OPU/JV/HCUs management control.

Example: A road hauler is working under a long term contract to deliver product on the OPU/JV/HCU's behalf. The hauler operates its own HSE-MS, has ISO 9000 and ISO 14001 accreditation and does not work exclusively for the OPU/JV/HCU. An incident which occurs during the time the hauler was delivering product for the OPU/JV/HCU would normally be included in the OPU/JV/HCU statistics as would the exposure hours.

Transportation within OPU/JV/HCU-managed locations / by OPU/JV/HCU-managed pipelines.

Transportation in PETRONAS branded road cars. Not considered to be work related Any incidents to Contractors not working under the OPU/JV/HCUs management control.

2. ENVIRONMENTAL INCIDENTS The purpose of this section is to illustrate with examples types of Environmental Incidents, and in particular to clarify what is an environmental incident. 2.1 OIL AND CHEMICAL SPILLS When a spill is not contained within the fence or system, it should be considered as an environmental incident. a) Fuel oil spill during work on pipeline A large diameter fuel oil pipeline in the off plot area of a refinery was being opened up for maintenance. Because the line had not been adequately cleared beforehand, around 1 tonne of fuel oil spilled into the pipe track. The majority ran off into the site drains but was collected in the interceptor system and recovered. None of the oil passed through the interceptor outfall to the stream.

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Although the spill was contained within the fence, it should be investigated to prevent recurrence. If the same spill had occurred under conditions of high rainfall and some of the oil had been discharged through the outfall and recovered from the stream, the spill should then be counted as an environmental incident. b) Diesel oil spill from ship A vessel was berthed in port. Diesel oil was being transferred internally from the wing tanks to fuel settling tanks. The settling tank overflowed spilling diesel onto the deck of the vessel and subsequently approximately 100 litres went into the harbour. The vessels Shipboard Oil Pollution Emergency Plan was put into operation and the oil was dispersed within an hour. The Authorities were notified. The master of the vessel was subsequently charged under section 12-2 of MARPOL for illegally discharging oil. This was clearly an environmental incident. The fact that the Authorities were involved, and the incident attracted local media attention, means that it should also be considered as a reputation incident. To avoid duplication the incident should be classified and reported on basis of the highest rating. c) Waste paint tins Three 5 litre tins of liquid paint all partly full were found in a general waste skip which had been returned from an offshore installation to a landfill site. The waste was detected by the landfill operator and constituted a "waste non-compliance". If it had gone into the landfill this would have breached statutory criteria and could have led to prosecution. Although it was spotted before it went in to the landfill this incident should be considered as a minor breach of statutory criteria, and therefore an environmental incident. As there had been previous non-compliances on that landfill location which had come to the attention of the local press, the impact on reputation should also be considered. ATMOSPHERIC EMISSIONS Fugitive emission of hydrogen sulphide. A refinery sour water pump seal failed and released hydrogen sulphide into the plant area, triggering the toxic gas detection/alarm system. The pump was quickly shutdown and isolated. There were no external complaints and it was estimated that the hydrogen sulphide in air concentration at the fence was below the odour threshold. 2.3 COMPLAINTS a) Noise complaint from local resident A resident of the community close to a refinery complained of a high noise intermittently overnight. The complaint was investigated and the source of noise tracked down to a compressor local alarm siren, which was faulty. Even though there were no prescribed maximum noise limits in the local community, the Complaint should be considered as an Environmental Incident. b) Smoke flare A call received from the Pollution Inspector that a member of the public had complained that a ground flare at a natural gas plant was exceptionally smoky over a weekend. The public living near the Plant have always taken an interest in HSE issues at the Plant, and the incident was discussed at the local community council meeting. If on investigation this proved to be a Justified Complaint it should be included as an environmental incident. Because of the local interest it would certainly count as a Reputation incident. To avoid duplication the incident should be classified and reported on basis of the highest rating.

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3 OCCUPATIONAL ILLNESSES 3.1 DETERMINING WHETHER AN ILLNESS IS OCCUPATIONAL The Occupational Health Management Guidelines define Occupational Illness as "any work-related abnormal condition or disorder, other than one resulting from an injury, caused by or mainly caused by exposures at work". In order to determine whether an employee's illness is occupational in nature, the following questions should be addressed:

Has an illness clearly been identified? Does it appear that the illness is caused, or mainly caused by, suspected agents or other

conditions at work? Are these suspected agents present (or have they been present) in the work environment? Was the ill employee exposed to these agents in the work environment? Was the exposure to a sufficient degree and/or duration to result in the illness condition? Was the illness attributable mainly to a non-occupational exposure?

OPU/JV/HCUs should check the "Material Safety Data Sheets" for those substances suspected of causing employee illnesses in order to verify the relationship between the exposure and the resulting symptoms.

3.2 RECURRENCE OF SYMPTOMS Companies are required to report each new Occupational Illness. The recurrence of symptoms from previous cases should not be reported. Deciding whether the emergence of illness symptoms constitutes a new event or the recurrence of a previous illness may be complex. Generally, each Occupational Illness should be reported with a separate entry. However, certain illnesses, such as silicosis, may have prolonged effects which recur over time. The recurrence of these symptoms should not be reported as a new case, unless the Occupational Illness results in death, permanent partial or permanent total disability. Some Occupational Illnesses, such as certain skin or respiratory conditions, may recur as the result of new exposures to sensitising or other hazardous agents, and should be reported as new cases. 3.3 PRE-EXISTING CONDITIONS An employee's physical or mental defect or pre-existing physical or mental condition does not affect the reportability of a subsequently contracted Occupational Illness. If in such circumstances an illness is caused or mainly caused by exposures at work, the OPU/JV/HCU must report it without regard to the employee's pre-existing physical or mental condition. 3.4 MEDICAL VERIFICATION BY A MEDICALLY QUALIFIED PERSON Medical verification is encouraged but not required for reportability. However, companies have the ultimate responsibility for reporting in good-faith. In case of doubt a medical opinion should be sought. If a company doubts the validity of an employee's alleged illness and there is no substantive or medical evidence supporting the allegation, the company need not report the case. The following examples are intended to clarify the boundaries between Occupational and non Occupational Illness, and also between Occupational Illness and Work-Related Injury.

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3.5 EXAMPLES OF OCCUPATIONAL HEALTH ILLNESSES a) BACK PROBLEMS A back problem shall be considered work-related if:

i) there is a clear record of an Incident such as a slip, trip, fall, sudden effort or blow on the back, or

ii) the employee was engaged in a work activity which produced a physical condition resulting

from a single identifiable over-exertion. A back problem shall be considered an Occupational Illness if it is caused by continued exposure to over-exertion. Example 1: A worker was installing a window-mounted air-conditioning unit. As the worker was sliding it into place, it tilted and started to fall. As the worker caught it and forced it into place, the worker felt a sharp pain in the back. This would be considered work-related Injury. Example 2: A woodcutter's foot slipped in the process of swinging an axe and a back pain developed immediately. This would be considered a work related injury, since the onset of symptoms was directly associated with a incident (slip) which occurred in the course of and arose out of employment. Example 3: An employee reported severe back pain which gradually developed towards the end of each workday, but could not attribute the condition to any specific event or activity. After reviewing the employee's work assignments, it was concluded that the condition resulted from continuous over-exertion in the performance of the employee's duties. The case, therefore, would be considered an Occupational Illness. b) BURNS Contact with a hot surface or a caustic chemical which produces a burn in a single contact would be defined as an injury. Sunburn or welding flash burns, on the other hand, which result from prolonged or repeated exposure, are considered Occupational Illnesses. c) CUMULATIVE MUSCLE STRAIN A cumulative muscle strain is where injury results from short-term over-stressing of a group of muscles. For example, a clerk who is usually involved in work that is not physically demanding is asked to assist in unloading a large shipment of heavy items by hand, a task which the clerk is required to do all day. Although the clerk feels no discomfort that day, the following morning the clerk's right shoulder and back muscles are so sore that the clerk is unable to perform the normal job effectively and has to be given specially selected duties. The injury was consistent with the type of work performed on the previous day and the case would be considered a work-related Injury. d) CARPAL TUNNEL SYNDROME Carpal tunnel syndrome is a condition involving compression of the median nerve in the wrist which results in tingling, discomfort and numbness in the thumb, index, and long fingers. Because work-related carpal tunnel syndrome cases almost always result from repetitious movement, they should be classified as Occupational Illnesses. The classification for these cases should be "disorders associated with repeated trauma" e) DERMATITIS A chemical worker contracted a mild case of dermatitis on both hands while working with a solution for several hours. The employee was sent to the doctor, who recommended application of a topical lotion (a commercial, non-prescription remedy). The employee bought a bottle of the lotion and treated the rash for a few days until it disappeared. There were no subsequent visits to the doctor. The rash did not prevent the employee from performing all the duties of the job. If considered an Injury, the case

33 PTS 60.0501 AUGUST 2010

would not be reportable since no medical treatment was provided. However, since the case almost certainly did not involve a single instantaneous exposure, it should be classified as an Occupational Illness. Consequently, the kind of treatment given by the doctor (none in this case) is immaterial, since all Occupational Illnesses are reportable. f) ANIMAL BITES AND INSECT STINGS Animal and insect bites and stings (and ensuing consequences ) are normally considered as work-related Injuries if such bites and stings occur in the course of employment. However, repeated exposure may result in disorders which are considered Occupational Illnesses. Example 1: A lineman engaged in routine work was bitten by a snake. The injury would be considered a reportable Injury. Example 2: A member of a party clearing jungle for seismic work was bitten by insects carrying the disease leishmaniasis. The resulting sickness would be considered an Occupational Illness. Example 3: Malaria or other diseases that result from a single bite, but involve multiple exposures to mosquito/insect stings, are classified as an Occupational Illness g) AGGRAVATION OF AN EXISTING PHYSICAL DEFICIENCY If aggravation of an existing physical deficiency arises out of an Incident in the course of employment, any resulting increased disability shall be considered a work-related Injury and classified according to the ultimate extent of the disability. Example 1: An employee with a known knee defect wrenched it whilst climbing down a ladder, when the bottom rung gave way. This aggravation required medical attention and would therefore be considered a work-related Injury. Example 2: An employee with a known knee defect suffered a recurrence of the disability while the employee was walking up steps. The incident arose "solely" out of the employee's pre-existing deficiency and therefore the resulting disability would not be considered a work-related Injury. Example 3: An employee with a blister unrelated to work knocked the top off the blister in the course of the employee's work activity. The broken blister became infected and resulted in lost time. This would be considered a work-related Injury. h) REACTION TO MEDICAL TREATMENT The reportability of an employee's disorder as a result of medical treatment depends upon whether the treatment was for work-related purposes. Example 1: An employee going on a business visit was vaccinated against cholera. Some days later the employee was taken ill and the illness was linked to the vaccination. This would be considered an Occupational Illness. Example 2: An employee is inoculated against influenza as part of a programme provided by the OPU/JV/HCU. An illness arising from the inoculation would be considered an Occupational Illness. Example 3: An employee is inoculated by OPU/JV/HCU medical personnel with a specific vaccine prescribed by an outside medical physician for treatment of a non work-related condition. An illness arising from defective administration of the injection would be an Occupational Illness but not if the illness arose from an adverse reaction to the vaccine.

34 PTS 60.0501 AUGUST 2010

i) INFECTED LACERATION An infection resulting from a laceration should be classified as a work related injury because the classification is based on the original event, the laceration, not on the subsequent developments. j) HEARING Noise induced hearing loss should be determined solely on the existing criteria contained in PTS 60.1504 Hearing Conservation Program. k) SPECTACLES An employee goes to a doctor who informs her that prescription glasses must be worn as a result of work-related eye deterioration caused by the nature of her job. If it can be established that the disorder was caused or mainly caused by exposures at work, this case would be reportable as an Occupational Illness since it involves the recognition of an abnormal condition or disorder. However, an OPU/JV/HCU should distinguish work-related eye problems from those due to ageing or hereditary factors unrelated to the job. l) HEART ATTACKS Work-related heart attacks are not classified as work related Injuries because they normally do not result from work accidents or single instantaneous incidents in the work environment. When they occur, they may be classified as an Occupational Illness, provided they satisfy the same requirements for work relationship as any other type of Occupational Illness. This means that heart attacks are not necessarily reportable if they occur in the work environment, but rather that they must result or mainly result from exposures at work. m) INDIVIDUAL SUSCEPTIBILITY Variations in the characteristics of particular employees of their susceptibility to various illnesses should not affect reportability. n) COMMON SUBJECTIVE SYMPTOMS Complaints of such common subjective symptoms as general malaise, headache, nausea, are not reportable if they are not caused or mainly caused by exposures at work. However, in evaluating these cases, one should be aware that many subjective complaints, including feelings of malaise, headache, nausea, etc., may be symptomatic of a wide range of diseases, a number of which are occupational in origin. In this regard, one should pay attention to the distribution of such subjective complaints with respect to time and place, particularly when such complaints are observed to occur among one or more groups of employees. Infectious diseases such as Malaria, Chagas disease are only reportable if they have been confirmed by clinical testing or by a doctor. If an illness is indigenous to the area and National personnel are diagnosed with these illnesses on a regular basis, they should not be reported. If the illness occurs among Nationals who normally do not suffer from the illness it should be reported. o) PERMANENT OR TEMPORARY TRANSFERS Permanent or temporary transfers to another job to remove employees from further exposure to health hazards are preventive in nature, and if no Occupational Illness has occurred, are not considered reportable events. p) WORK-RELATED STRESS Only report those cases where t