incident - accident reporting procedure
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Accident-Incident Reporting Procedure
ACCIDENT-INCIDENT REPORTING
PROCEDURE
Document Revision Status
Nnochiri Ogbonna Michael Nnanna
0 15.06.13HSE
COORDINATORGM-ENGINEERING
SERV/ CORPORATE
MD
Rev.
Date Prepared Reviewed Approved
HAMMAKOPP CONSORTIUM LIMITED
HAMMAKOPP BASE
Km 25 Onitsha Owerri Express Way
Umuezedam Okija
Anambra State.
2013
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TABLE of CONTENTS
INTRODUCTION 41.1 General 41.2 Objective of the Procedure 51.3 Purpose of the Procedure. 61.4 Definitions and Abbreviations. 71.5 References 72.0 Responsibilities 8
3.0 Incident Reporting, Investigation & Communication 9
Emergency Contacts 9
Emergency Flow Charts 10
4.0 Purpose of an Effective Investigation . 11
5.0 Major Incident Notification Process 12
Incident Potential Matrix 15
Immediate Incident Notification & Reporting Matrix 17-18
Attachments
Attachment 1 Accident Reporting Form-Blank Copy 19-26
Incident Notification Form
Near-miss Reporting Form
Detailed Incident Investigation Report Format
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REVISION HISTORY
Revision Date Page Description Approved
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INTRODUCTION
General
Hammakopp Consortium Limited HSE Management System requires management
commitment at all levels as to ensure that all accidents are prevented and unsafe
conditions identified with control measures put in place to mitigate any undesired
occurrence.
Sound HSE MS implementation is geared towards accident prevention considering the
high cost (direct & indirect) of accidents to an organization.
Employees have the obligation to report unsafe acts and unsafe conditions, while
HSE advisors conduct risk assessments jointly with construction team as to identify
inherent hazards associated with all activities, and proffer controls as to prevent
accidents.
Reportable Acc ident Types;
Fire Incidents
Medical Incidents
Security Incidents
Environmental Incidents
Equipment/Facility/Asset Damage Incidents
Direct costs of an accident are;
Medical Costs:
Cost of treatment, additional associated medical costs, hospital and physician
bills, occupational therapy, prescription medicine and medical equipment
Compensation Costs:
Insurance, replacements, repairs and workmen compensation insurance policy
implementations.
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Indirect Costs of an accident;
Like an iceberg, the unseen indirect costs of accidents are much larger than the directcosts above. Indirect costs associated with workplace accidents and injuries include
damage to the equipment the worker was using, loss of work time, production loss and
cost to hire (a permanent or temporary replacement for the employee), training and re-
training, cost of accident investigation, legal or police charges etc.
Other indirect hidden costs include the possibility that the employer's insurance premium
may raise rise because of the accident. Indirect costs associated with workplace accidents
and injuries can total as much as three or four times the amount of the direct costs andmay amount to 30 times the amount spent for direct costs, depending upon the type of
accident that occurred.
Production delays/interruptions
Product and material loss or damage
Equipment or Facility Damage
Client Dissatisfaction
Employee Training Overtime Costs
Loss in productivity
Corporate Image/media
So every effort must be made to prevent accidents from happening!
1.2 Objective of the Procedure
The objective and purpose of this document is to provide Hammakopp Consortium
personnel with basic information that will serve as guidelines regarding standards of
accidents and incident reporting and investigation. It attempts to establish and define
responsibilities for different level of management as well as employee responsibilities in
the event of an accident. It also defines the various levels of accidents as it relates to
Hammakopp Consortium operations.
Some details represented in this document may be revised from time to time to meetchanges that may occur for various reasons. However, it is Hammakopps intention to
adhere to this procedure as much as practicable.
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1.3 Purpose of the Procedure.
This procedure will similarly fulfil the purpose listed below:
Documenting a procedure for accident reporting and investigation;
Establishing in clear terms reporting lines and timelines for reporting accidents
Provide the mechanism for rating accidents and their investigation levels
Identifying critical issues and potential constraints;
Defining responsibilities of the management and Employees
Facilitate the briefing of Hammakopp Consortium personnel and provide them
with a guideline regarding accident reporting and investigation.
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1.4 Definitions and Abbreviations.
Non-conformance- A condition or event which deviates from established procedures.
Near Miss- an incident that does not result in loss but could have, given slightly different
(but credible) circumstances
Accident- an unplanned, undesired incident which results in loss or damage to properties,assets, equipments, facilities, environment etc.
Loss- The unnecessary waste of resources, including:
PEOPLE: fatality, injury, illness
PLANT/EQUIPMENT: damage, repairs, replacement
PROCESS: interruption
AMENITY: environment pollution
GOODWILL: adverse publicity
1.5 References
Hammakopp Consortium Limited accident-incident reporting and investigation
Procedure.
Hammakopp Consortium Limited HSE Manual
Hammakopp Consortium Limited HSE Plan for construction activities
Accident report and investigation form.
.
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2. 0 RESPONSIBILITIES
Management-:
Ensure that all accidents/incidents and non-conformances are reported and
documented.
Ensure that immediate and remote causes of accidents are identified,
cascaded, and corrective actions taken to prevent the recurrence of an accident/
incident or non-conformance.
Ensure that unsafe conditions requiring management commitment are
addressed as to prevent unwanted occurrence.
Ensure the provision of resources required to address accident related issues.
Ensure timely provision of emergency / contingency equipments.
Maintain effective communication with responsible parties in the event of an
accident.
Ensure the mobilization of security personnel when required.
Employees
Ensuring their work activities does not harm themselves, others or the
environment.
Take reasonable actions to prevent incidents and non-conformances.
Report incidents and non-conformances immediately to their supervisor.
Identify unsafe conditions, proffer immediate remedial actions or report unsafe
conditions to their supervisor or HSE department.
Fill the HIR form when required.
Use fit-for-purpose equipments and tools to carry out work activities.
ERT/HSE
Initiates emergency response/ rescue operations
Communicates responsible parties and maintains effective communication
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3.0 INCIDENT REPORTING, INVESTIGATION AND COMMUNICATION
Incidents are reported immediately to supervisors, HSE advisors and management
depending on incident severity.
The incident reporting and investigation form is used for reporting, investigating and
tracking incidents to closure
Lessons from and information on non-conformances and incidents are communicated
using HSE Alerts, accident/incident review and HSE meetings and/or daily toolbox talks
mediums.
Emergency Contacts;
NAME DESIGNATION PHONE
K. C AKUMA MD 08033241099
NNANNA MICHAELGM Engr & CorporateServices
08036719422
CHUKWUNWIKE ALEX GM Projects 08033402965
CHUKWUDUM IKENNA Legal/SCD/Pro/Contracts 08034727156
FEROZ JADOON Construction/Project Manager 08037936436
JOITI KUMAR AGM - Maitenance 08030896640
HUSSEIN MOHAMMED Senior Site Engineer 08160595035
WILLIAMS OLATOYE Engineering Coordinator 08033150389
NNOCHIRI OGBONNA HSE Coordinator 08036719585
ESIEKPE ISAAC HSE Supervisor 07034547809
HENRY IWUCHUKWU Chief Security Officer 08038804602EWUZIE UCHE Transport/Logistics Officer 08060824186
COKER MICHAEL Asset Officer 08034934641
OGBONNA FRANCIS Site Nurse 08075790861
MIRIAM IFEANYI Base Nurse 07065322241
JUDITH OKOLI HR Officer 08075790867
ALEX ISOGIE HSE Officer-PH Base 08158990940
SOLOMON HSE Coord- Uyo Base 08037534461
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Emergency Flow Chart
Call On-Scene
Commandant
(OSC)
GM.
08036719422
,07028180801
or Code 1045
HSE Co-ord, Site/Base
Nurse will assess
situation and take
action.
08036719585/
07065322241
Coordinate with Project
Mgt. Team.GM-Projects-08033402965
PM/CM-08037936436
Access theSituation & report
Provide adequate
First Aid or Med.
Assistance.
Investigate , Report &
make
Recommendations
Project Mgt. team to
determine course of
action
Moves Victim to
Hammakopp
Retainer Clinic
Medevac +
Evacuation Required?
Hamakopp to initiate
Evacuation . Stabilize
Contact Client Site
Rep.
Investigate
&Report to Client
24hrs
Contact Project
Mgr to MEDVAC +
Evacuate Victim
Coordinate with
Evacuation/
MEDEVAC Provider
Inform the Base
Office
Inform MEDEVAC
Provider
MEDICAL /EVACUATION EMERGENCY REPONSE FLOW CHART
Case Cannot be managed
InternallyAdminister First Aid and
Communicate
MEDEVAC ProviderIf needed
No need for MEDEVAC
Case Can be
managed
internally
08033241099---- -MD
08036719422------GM-Engr Services/Corporate
08033402965------GM-PROJECTS
08034727156------Legal/SCD/Pro/Contracts
08037936436------PM/Construction Manager
0816059503-------Hammakopp const. Abuloma
07065322241------BASE NURSE
08035973880 -----SITE NURSE
08036719585------HSE COORDINATOR
07034547809------HSE SUPERVISOR.
08063572178 -----Medical-Medridian Hosp-PH
08034877736-----HSE OFFICER-Abul oma, Site PH08063487200----HSE OFFICER- Ichi Site, Anambra
08033241099---- -MD
08036719422------GM-Engr Services/Corporate
08033402965------GM-PROJECTS
08034727156------Legal/SCD/Pro/Contracts
08037936436------PM/Construction Manager
0816059503-------Hammakopp const. Abuloma
07065322241------BASE NURSE
08035973880 -----SITE NURSE
08036719585------HSE COORDINATOR
07034547809------HSE SUPERVISOR.
08063572178 -----Medical-Medridian Hosp-PH
08034877736-----HSE OFFICER-Abul oma, Site PH08063487200----HSE OFFICER- Ichi Site, Anambra
Phone Lines
MD-07028002304,08033241099
DPR-084-3290000 &084-4611777
FEMENV-08032557931.
Retainer Clinic- Our Lady of
Lourdes Ihiala 08135700630
Retainer Clinic- PH-Meridian:
08063572178
MD-07028002304,08033241099
DPR-084-3290000 &084-4611777
FEMENV-08032557931.
Retainer Clinic- Our Lady of
Lourdes Ihiala 08135700630
Retainer Clinic- PH-Meridian:
08063572178
Important Lines
CaseCannot be
managed
Internally
Emergency
Incident Observedat Site/Base/
Camp
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4.0 PURPOSE OF AN EFFECTIVE INVESTIGATION.
A good and timely incident investigation can help us:
describe what happened
determine the immediate and root causes
evaluate the risks
develop controls
define trends
demonstrate concern
And which ultimately lead to:
fewer incidents
reduced incident costs
lower incident rates/potential
increased confidence /morale (client & employee)
higher profit margins
4.1 Which Incidents Shou ld Be Investigated?
We must investigate all incidents to determine which has the potential for major or
serious loss!
We should give special attention to those with high potential for loss
5.0 INCIDENT CLASSIFICATIONS
There are three major classes of incidents.
1) Major accidents
2) Serious accident
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3) Minor accidents.
MAJOR INCIDENT NOTIFICATION PROCESS.
Overview
Hammakopp Consortium employees are responsible for preventing incidents by
following safe and environmentally sound practices and procedures. When a Major
Incident occurs, local employees first priority is to respond to the immediate needs of
the situation and notify direct supervisors and managers to provide assistance with this
response. Additionally, for Major Incidents, an immediate call to the operating base is
required. The single hotline call ensures that support departments such as Legal,
Contracts, Assets and Logistics, the HSE Departments, security and appropriate
Management executives are kept informed of Major Incidents. This notification process
reduces the burden on local management and personnel and allows them to be
dedicated to emergency response and external notifications (e.g., responders,
agencies, clients, etc).
5.1 MAJOR INCIDENT DEFINITION
Incident involving loss of life or major injuries (e.g., amputations, serious eye and head
injuries, injuries requiring emergency hospitalization, etc).
Extensive property or equipment damage in excess of $50,000
Fatal road traffic accidents resulting to death(s).
Explosions, loss of radiation sources, or blows out events where Hammakopp
Consortium personnel or equipment are present.
Fires requiring outside assistance from emergency services.
Radiation releases exceeding the reportable quantity
Chemical spills or releases that meet or exceed the l reportable quantity; any
spills of 55 gallons (208 liters) or more which occur at a clients facility, during
transport, or at a public location
Any incident involving Hammakopp Consortium employees, products or
services at a client or Hammakopp Consortium location with likely public
consequence or potential media attention
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Security Incident: may include, but not be limited to threats to personnel or
property (e.g., bomb threats), requiring the need to evacuate personnel from a
location, reports of actual or threatened extortion, kidnapping of personnel orcontractors, reports of civil, political, or labor unrest in a location.
Loss or theft of explosives or radiation sources.
Collapse of buildings
Natural disaster e.g flood, earthquake
5.2 SERIOUS ACCIDENTS DEFINITIONS
Any incident not mentioned in the previous definitions involving the following
Personal injury involving medical beyond first aid.
All days away from work cases
Fires handled by local staff
Property or equipment damage not exceeding $10,000 dollars
Chemical spills or releases that meet or exceed the local reportable quantity; any
spills of 55 gallons (208 liters) or more occurring at Hammakopp Consortium base
only.
5.3 MINOR ACCIDENTS DEFINITIONS
Any incident not mentioned in the previous definitions involving the following
Personal injury requiring first aid treatment.
Minor property damage (dents, broken minor glasses) between $1-$10,000 dollars.
Chemical spills or releases not exceeding the local reportable quantity; occurring at
Hammakopp Consortium bases only.
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5.4 HOTLINE CALL PROCESS
An employee involved in, or witnessing, an incident will report the incident to their
supervisor. If the supervisor is not available the employee is to contact the local or
local HSE Rep or the Site Manager (Reference emergency contact numbers).
The supervisor, either alone or in conjunction with the local HSE representative and/or
local emergency response coordinator, decides if the situation is a Major Incident. If
yes, it must be reported to the responsible manager and the HSE Coordinator. This
report must be madeimmediately after incident stabilization and at least within two
hours.
For severe incidents that do not appear to meet the exact definition or examples of a
Major Incident, please use your best judgment and initiate a hotline call as appropriate.
(When in doubt, always report)
In situations where the major incident scenario is evolving (e.g., loss of source,
employee hospitalization), the employee making the notification and/or the Emergency
Coordinator is expected to make a follow-up notification to provide updated or closure
information when appropriate. This information will be updated in the written record
and communicated to the appropriate authorities. Phone calls must give the following-:
Name of Caller:
Callers contact number:
If caller is an employee, supervisor or other
Type of Incident:
Affected Employee Name:
Specific location ( site, customer site or other):
Address:
Description of the incident: A clear description of the incident must be provided
by the caller.
Any immediate response need: Information on additional assistance that may
be needed.
Other parties notified (Client, personnel, government agency, authorities, etc.)
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5.5 INCIDENT POTENTIAL MATRIX
Incident Severity.
Number of persons Involved.
0 1 2-10 11+
Major 1 Level 2 Level 1 Level 1 Level 1
Serious 2 Level 3 Level 2 Level 1 Level 1
Minor. 3 Level 3 Level 3 Level 2 Level 1
This matrix determines the investigation level of accidents in Hammakopp. However in
arriving at this format, the major Considerations are as follows-:
the severity of the incident (or its potential); and
The number of persons involved (or its potential.)
Selection of investigation team members depend upon the determination of the severity
of the incident.
5.6 WHO SHOULD INVESTIGATE INCIDENTS?
From the matrix above, these are the responsibilities as it applies to the different levels
in accident investigation in Hammakopp Consortium Limited-:
Level 1 Investigations are undertaken by the following-:
Line Supervisor/Manager.
Location or Project Manager/Project Engineer
MD/or management Rep.
HSE Coordinator/Manager.
Local HSE Representative
Others as deemed necessary (e.g., CSO, PRO/CLO, Asset/Logistics, staff
personnel)
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Level 2 Investigation is undertaken by the following-:
Line Supervisor/Manager - Leader
Group or Department Manager
Local HSE Representative
Others as deemed necessary (e.g., staff personnel)
Level 3 Investigations are undertaken by the following-:
Line Supervisor/Manager - Leader
Others as deemed necessary (e.g., staff personnel)
Supervisors should take the primary investigative role because they know:
An accident occurred in their area
The decision(s) made, equipment used, and
other factors which may have caused the accident
The capabilities and limitations of the
personnel involved in the accident
The procedures that were used or should
have been used
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5.7 HAMMAKOPP IMMEDIATE INCIDENT NOTIFICATION AND REPORTING MATRIX.
INCIDENT SEVERITY
PERSON TO CALL:MAJOR(within 2hours)
SERIOUS orSignificant NearMiss(within 12hours)
MINOR or NearMiss(within 24hours)
BASE/ENGINEERING CONTACT.
Name ..............Michael Nnanna
Mobile phone:..08036719422, 08075790844
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
PROJECTS CONTACT.
Name ................Alex Chukwunwike
Mobile phone:....08033402965, 08075790845
Phone / e-
mail
Phone / verbal Phone / verbal
/ e-mail
MAINTENANCE CONTACT.
Name ...................Joythi Kumar
Mobile phone:................, 08075790872
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
LEGAL/SCD/PRO CONTACT.
Name ...................Ikenna Chukwudum
Mobilephone:................08034727156,08075790846
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
CONSTRUCTION CONTACT
Name . .........................N.F.Jadoon
Mobile phone.....................08075790847
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
CONSTRUCTION PH BASE CONTACT
Name . ..............Mohammed Hussain
Mobile phone.........................08158990938
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
HSE CONTACT.
Name .................Nnochiri OgbonnaMobile phone......08036719585, 08075790850
Phone / e-mail Phone / verbal Phone / verbal/ e-mail
ASSET CONTACT.
Name ...............Micheal Bayo Coker
Mobile phone......08034934641, 08075790862
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
TRANSPORT CONTACT.
Name ................Felix Ewuzie Uche
Mobile phone......,............ 08075790852
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
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HAMMAKOPP HSE PH BASE CONTACT.
Name ..............................Alex Isogie
Mobile phone.........................., 08158990940
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
HAMMAKOPP HSE UYO BASE CONTACT.
Name ..............................Solomon
Mobile phone.........................., 08037534461
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
CSO CONTACT.
Name ..................Iwuchukwu Hilary
Mobile phone.........................., 08075790868
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
EMERGENCY RESPONSE TEAM
Name . Isaac Esiekpe-08075790851.
Name ..............Emmanuel Nworie-08063487200
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
CLINIC CONTACT
Name: Ogbonna Francis -08075790861
Name: Miriam Ifeanyi - 07065322241
Phone / e-mail
Phone / verbal Phone / verbal/ e-mail
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ATTACHMENTS-:
ATTACHMENT I ACCIDENT REPORTING FORM-BLANK
ATTACHMENT 2 NEAR-MISS INCIDENT REPORT FORM\
ATTACHMENT 3- DETAILED ACCIDENT-INCIDENT REPORT FORMAT
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INCIDENT REPORT FORM
DATE OF INCIDENT: TIME OF INCIDENT:
LOCATION OF INCIDENT:
INCIDENT/ACCIDENT TYPE (TICK APPROPRIATE BOX)
INDUSTRIAL SECURITY
LOST TIME INJURY COMMUNITY
MEDICAL TREATMENT CASE ENVIRONMENTAL/SPILL
FIRE NEARMISS
MARINE OCCUPATIONAL HEALTH
ROAD TRAFFIC OTHERS
NATURE OF SECURITY INCIDENT: ________________________________________
NATURE OF COMMUNITY INCIDENT: ________________________________________
STAFF/EQUIPMENT INVOLVED: ________________________________________
EVENT LEADING TO THE INCIDENT:
IMMEDIATE ACTION TAKEN:
____________________________________________________________________________________
____________________________________________________________________________________
_________________________________________________________________________________
INCIDENT/ACCIDENT ANALYSIS/CONCLUSION:
________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________
RECOMMENDATION:
NAME OF REPORTER SIGN. DEPT. DATE
FURTHER INVESTIGATION REQUIRED? [YES/NO] HEAD OF DEPT. SIGN/DATE.
NOTE: THIS FORM MUST BE COMPLETED AND FORWARDED TO HSE COORDINATOR WITHIN 24HRS OF INCIDENT.
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NEAR-MISS REPORT FORM
PROJECT: ______________________________ LOCATION : ____________________
PLACE OF INCIDENT: ______________ DATE:_____________ TIME:______________
PERSONNEL INVOLVED EQUIPMENT/MATERIALINVOLVED
1. ----------------------------------------- 1. ------------------------------------------
2. ----------------------------------------- 2. ------------------------------------------
3. ----------------------------------------- 3. ------------------------------------------
DESCRIPTION OF NEAR-MISS INCIDENT:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________________________________________
IDENTIFIED REASONS FOR THE INCIDENT:
____________________________________________________________________________________
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
REVIEW/RECOMMENDATION/LESSON LEARNT TO AVOID RE-OCCURRENCE:
____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________
REPORTED/OBSERVED BY: _________________ SECTION/DEPT._____________________
RECORDED BY: _____________ DESIGN:_______________ SIGN:____________
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DETAILED INCIDENT INVESTIGATION REPORT FORM
1 Anomaly/Incident Description Summary (Facts only) Enter here a brief description of the incident.
2 - Incident Classification Verification
Date: Time: Activity:
Site: Exact Location: Report Number:
Type DamageCategory
Severity Human LossClassification
Anomaly
Near Miss
Incident
Human Loss
Environmentalloss
Prod/MatLoss
Media
Actual Potential First Aid
Medical Treatment Case
Restricted Work Day Case
Lost Time Injury SingleMultiple
with estimated_Days Lost
Illness Fatality
1 - Minor2 -
Moderate
3 - Serious
4 - Major
5 -Catastrophic
1 - Minor2 - Moderate
3 - Serious
4 - Major
5 - Catastrophic
3 - Incident Information
3.1 - Human Loss/Injury & Victim Information (remove section if not used)
Name (s) Age Senioritydate
COMPANYContractor
orThird Party
Jobfuncti
on
Hrssince
lastsleep
Hrsslept
lasttime
Hrson
duty
Typeof
loss
Indicate details on injuries for each of the persons above
Injury Body partsaffected
Dayslost
(estimated)
Medical Officer Name: _____________ Signature ______________
3.2 Vehicle Incident Information (Remove section if not used)
Was vehicle travelling in convoy : Yes No Was the driver the only occupant? Yes No
Was Vehicle Company Owned Rented/Leased Personal Vehicle On Company Business Yes No
WeatherConditions
Road Type Accident Type
Dry Paved Unpaved Hit vehicle in front Sideswipe
Wet/slick Off road Curve Hit from behind Passing
Clear Up a grade Downgraded Backed into Being passed
AHeadBFace
HFingersILegs
A CutB Heat BurnCFracture/breakD Amputation
H ChemicalburnISprain/strainJ BruiseK Crushing
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Dust Narrow Poor surface Hit stationaryobject
Hit & Run
Fog Hit pedestrian Hit animal
Rollover Ran off road
Alcohol or drugs involved? (Testingrequired)
Yes No Results of alcohol test _____ g/l Measured __ hrs after event
Speed when accidentoccurred
______ km/h Driving Certificate held? Yes No
Driving monitor present and working? Yes No Charged by Police? Yes No
All persons wearing seatbelts? Yes No Defensive Driving Training up todate?
Yes No
3.3 - Environmental Incident Information (Remove section if not used)
Result Details
Vegetation damage Release to water way Amount spilled or
discharged:
Unit
Soil contamination Released to air Material name or code :
Ground watercontamination
Marine life damage Duration of discharge: hrs Min
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3.4 - Asset, Material or Production Loss Information (Remove section if not used)
Other Loss Information
(Equipment, property, products, information, time or other including those of Third Party)
Type:
Description of loss Quantity
Unit
4 - Incident Cost Estimate (Remove section if not used)
Injury/Illness Costs($000) Automotive Costs ($000)
Environmental Costs($000)
Other Costs ($000)
Lost WorkDays
Replacements
LostProducts
Replacements
Temp Staff Repairs Remediation Repairs
MedicalCosts
3rd PartyRepairs
LitigationLostProducts
Litigation/Other
Litigation/Other
OtherLostRevenue
Total Total Total Total
Remarks :
5 - Investigation
Name of Manager leading the
Names of other team members:
Investigation Section 5.1 - Immediate Causes (Key Words)Contact/ Fall Electrocution Marine Trans ort incidentExposur
Struck by Drowning Gas leak
N/A Caught between Vehicle incident Liquid hydrocarbon leakExplosion or burns Air transport incident Other
Investigation Section 5.2 - Immediate Causes (Practices & Conditions)
Unsafe Procedure Material tools & e ui ment Unsafe Position / PostureFailing to secure plant Using Unsafe Loading / Lifting
Failure to follow procedure Unsafe Use of Correct Tools / HorseplayFailure to warn of inform Servicing equip in Failure to Make Plant SafeOperating at improper speed Failure to check equip Unsafe Mixing, Placing,erformin hazardous liftin or loadin Dru induced Servicin e ui in o eration
Unsafe Inade uate Guards or Barriers Pressure ex osure Substandard Housekee inSituation Inadequate PPE Slippery surface Corrosion / Slow Damage
Defective Tools, Equip, or Mat. Defective Plant / Excessive Noise orCongestion / Poor Access Wear and tear Inadequate VentilationInadequate Warning System Radiation exposure Safety devices inoperable
Inadequate Illumination Hazardous Atmospheric
Investigation Section 5.3 - Root Causes
(Which of the following Human and/or Job Factors were the Basic Causes of this accident?)
Human FactorsJob Factors
Lack ofknowledge
InadequateTraining
Inadequate Leadership / Supervision Inadequate Job Planning
Inadequatecapability
ImproperMotivation
Inadequate EngineeringInadequate tools, materials,
equip.
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Stress Fatigue Inadequate Purchasing Inadequate Work Standards
SubstanceAbuse
InattentionInadequate Work Instructions
ProceduresInadequate Maintenance
Lack of
AwarenessLack of Sleep Inadequate Risk Assessment
Inadequate
Plant/Machinery/Equip.Inadequate Definition of
ResponsibilitiesAbuse or misuse
Investigation Section 5.4 - Root Cause
(Refers to MS Dysfunction)
The fundamental or root causes are selected from one of the 14 elements listed belowRespect of laws &
regulationsRespect for the
EnvironmentEmergency
PreparednessCriminal act / ill will
ManagementResponsibilities
Safeguarding of Health Incident Analysis Other
Operational Responsibilities Contractors & Suppliers Audits & Inspections
Risk Evaluation &Management
Competence & TrainingPerformance
Improvement
6 - Other Information (Interviews, Pictures, etc.)
Include in this section a summary of all the information collected during the investigation. Placesupporting documents at the end of the report as Appendix.
1) Winess Report2) Preliminary Incident Notification
3) Investigation Report4) Photograph
7 Cause Tree Analysis State Causes (FACTS-ONLY)
Insert the cause tree analysis in this section.
8 - Corrective Actions
Enter below corrective actions required to address immediate, basic and root causes. Specify WHO and WHEN.
ItemNo Recommendation
Action Item Person
Responsible
TargetDate
Complet
ion.Date
Remarks
1
2
3
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9 - Review and Endorsement
Comments by Reviewing Manager
Endorsements
Reported By (Name): Signature: Date:
Noted By (Name): Signature: Date:
For HSE Division: Signature: Date: