Documente Academic
Documente Profesional
Documente Cultură
GUIDELINE
PTS 60.0501
AUGUST 2010
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)
2)
3)
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.
PTS 60.0501
AUGUST 2010
Acknowledgement
This document was jointly prepared with contribution from the following persons and their respective
organizations.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Sulo Belawan
(Advisor)
Sazali Abu Kassim
(Lead)
Busari Jabar
W Idrus W Sabli
M Zainudin M Zain
M Jasbir Khan Abdullah
M Farizuddin Anwar Mansor
Ibrahim Hamid
A Hisham Mohamad
Ozair Saidin
Roselan Mohamad
Ahmad Tarmizi Jaafar
Rosnan Hamzah
M Hadzir M Said
Chee Tze Chian
Zukri Zainon
M Hazman Hamzah
Azharin Ahmad
GHSED
GHSED
GHSED
GHSED
GHSED
GHSED
GHSED
MLNG
PDB
PGB
PGB
PCSB
PCSB
PPMSB
MISC
CSD
CSD
CSD
PTS 60.0501
AUGUST 2010
TABLE OF CONTENTS
1.0
2.0
3.0
INTRODUCTION .................................................................................................................. 7
1.1
Objectives .................................................................................................................. 8
1.2
1.3
2.2
References ............................................................................................................... 11
DEFINITIONS ..................................................................................................................... 11
3.1
4.0
5.0
4.2
4.3
4.4
4.5
4.6
5.2
5.3
5.4
7.0
Notification ................................................................................................... 14
Immediate Corrective Actions ..................................................................... 15
6.0
Purpose ........................................................................................................ 18
Involvement of People ................................................................................. 18
Underlying Causes....................................................................................... 19
Recommendations ....................................................................................... 19
Consequence Management ......................................................................... 20
FOLLOW-UP ...................................................................................................................... 20
6.1
6.2
Implementation of Recommendations.................................................................... 21
6.3
6.4
PTS 60.0501
AUGUST 2010
7.1
7.2
................................................................................................................................... 69
PTS 60.0501
AUGUST 2010
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,
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
PTS 60.0501
AUGUST 2010
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
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,
PTS 60.0501
AUGUST 2010
1.2
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
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:
awareness that reports may be required by third parties such as national authorities,
legal bodies, etc.
PTS 60.0501
AUGUST 2010
Duration
Within 24 hours after incident
Incident Notification
(Minor: Rating 3)
Within 24 hours after incident
Incident Notification
(Major: Rating 4 & 5)
Within 1 hour after incident
HSE Alert
(Major Incident)
Lesson Learnt
(Major Incident)
Final Investigation Report
(Major Incident
Follow-Up Report
(Fatal Incident)
Monthly Incident (Summary)
Reporting
To Who
OPU/JV/HCU internal
management
COMCEN
Head GHSED
Respective VP
OPU/JV/HCU internal
management
Authority
Presidents Office
EVPs Office
Country Manager
VP Legal
10
PTS 60.0501
Reporting Company
This document applies to those Companies/Joint Ventures/Holding Company Units where the
PETRONAS has full authority to introduce and implement:
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
2.0
DEFINITIONS
3.1
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)
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
11
PTS 60.0501
AUGUST 2010
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
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
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)
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:
12
PTS 60.0501
AUGUST 2010
assistance required
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
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
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).
13
PTS 60.0501
AUGUST 2010
4.6
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
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
5.1.3
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
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:
b.
14
PTS 60.0501
AUGUST 2010
c.
5.2.2
5.2.3
Investigation Team
a.
General
The size and composition of an investigation team should depend on factors such
as:
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
15
PTS 60.0501
AUGUST 2010
c.
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
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:
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:
16
PTS 60.0501
AUGUST 2010
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
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.
17
PTS 60.0501
AUGUST 2010
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
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
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.
18
PTS 60.0501
AUGUST 2010
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.
19
PTS 60.0501
AUGUST 2010
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:
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
FOLLOW-UP
6.1
20
PTS 60.0501
AUGUST 2010
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.
Each OPU/JV/HCU should report the summary of incidents monthly to Group HSE Division
21
PTS 60.0501
AUGUST 2010
for consolidation and reporting to higher management. The summary report should follow the
th
form as per Appendix 9 and should be submitted to Group HSE Division by 10 day of each
month. The same requirement should be reflected in the iHSE system.
7.0
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
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
22
PTS 60.0501
AUGUST 2010
23
PTS 60.0501
AUGUST 2010
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.
24
PTS 60.0501
AUGUST 2010
OPU/JV/HCU PREMISES
OPU/JV/HCU premises are:
-
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)
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.
25
PTS 60.0501
AUGUST 2010
26
PTS 60.0501
AUGUST 2010
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 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;
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.
27
PTS 60.0501
AUGUST 2010
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 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)
OPU/JV/HCU and Contractor personnel commuting between home and normal work place on
other than OPU/JV/HCU arranged transport.
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 workrelated.
28
PTS 60.0501
AUGUST 2010
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
Considered to be work-related
1.3
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.)
TRANSPORTATION OF PRODUCT
Considered to be work-related
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.
locations /
by
OPU/JV/HCU-managed
2.
Any incidents to Contractors not working under the OPU/JV/HCUs management control.
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
When a spill is not contained within the fence or system, it should be considered as an environmental
incident.
a)
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.
29
PTS 60.0501
AUGUST 2010
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)
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)
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 noncompliances 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)
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.
30
PTS 60.0501
AUGUST 2010
OCCUPATIONAL ILLNESSES
3.1
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:
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?
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 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.
31
PTS 60.0501
AUGUST 2010
3.5
a)
BACK PROBLEMS
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.
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)
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 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 workrelated 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
32
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 and insect bites and stings (and ensuing consequences ) are normally considered as workrelated 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)
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)
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.
33
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
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 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 there is an identifiable organisational and/or interpersonal factor in
relation to work and the working environment which has resulted in a stress related disorder requiring
34
PTS 60.0501
AUGUST 2010
significant intervention such as specific counselling or treatment, modification of duties or loss of time
from work.
4
a)
REPORTABLE INCIDENT
i)
Injurious incidents involving contractors personnel at oil platform fabrication yard where
elements of company management controls exist.
ii)
iii) Injurious incidents involving company personnel at locations not belong to PETRONAS
such as NIOSH. The statistics should go to OPU/JV/HCU if there is negligence from the
personnel. Otherwise, it is categorised as Recordable Incident.
iv) Fire due to lightning.
v) Damage to companys asset due to act of sabotage.
vi) Visitor fell through uncovered/broken drain grating in the company premise.
vii) Injury while playing football due to major trip hazards or structural failure of goal post in
playing field managed by the company.
viii) Injurious incidents while doing company activities or work including the outsourced
activities or work carried out by contractors and sub-contractors during working hours
including shift hours, lunch hours and overtime at company premise.
ix) A robbery inside a security protected area such as office and depots where
managements control exists.
x) Injurious incident while doing company activity/work including outsourced activity during
the working hours at third party premise or public area where the company has full control
of the event.
xi) Injurious incident while doing company activity/work while using company vehicle or
company arranged vehicle including delivering products to customers either within
company premise or outside company premise.
b)
RECORDABLE INCIDENT
i)
ii)
iii) A football player playing inside the company premise sprained his ankle after being
tackled by opponent player.
iv) Injurious incident while doing company activity/work including outsourced activity during
the working hours at third party premise or public area where the company has no control
of the event.
v) Injurious incident to or from work place to home.
vi) Injurious incident outside company premise after working hours.
35
PTS 60.0501
AUGUST 2010
vii) Injurious incident while transporting equipment from supplier warehouse/shop to company
premise as the controls of transportation fall under the supplier.
viii) Injurious incidents while travelling using public transportation on company activity/work.
5
OTHER EXAMPLES
a)
ENTERTAINMENT OF OR BY CUSTOMER, SUPPLIER OR OTHER BUSINESS
CONTACTS
An illness caused or mainly caused by exposures which occur while the employee is entertaining a
customer, supplier or other business contact, or while the employee is being entertained by a
customer, supplier or other business contact, for the purpose of transacting, discussing, or promoting
business, would be considered an Occupational Illness.
b)
HORSEPLAY
An injury inflicted by, or arising out of, horseplay during work shall be considered a work-related
Injury. For example, an employee was showing off by operating a fork lift which the employee was not
familiar with nor authorised to use. The employee lost control, struck another employee and was
injured. Although the employee was engaged in a prohibited activity, the employee's injury, as well as
that occurring to the fellow employee, would be considered a work-related Injury.
c)
An employee attends a training course at a training school or other site and sustains an Injury. The
training period is to be considered as a normal work period for reporting purposes. If the Injury is
sustained during the duration of the training sessions then it is a work-related Injury. However if the
Injury occurs in the employee's own recreational time, and is not attributable to failure of management
controls of the training centre, then it is not work-related.
The Injury is included in the statistics of the Company employing the injured person as are the
exposure hours, unless if there is negligence of controls by the training centre. In this case, statistics
belongs to the training centre. The responsibility for the investigation and follow up rests with the
training centre. The employing Company should receive a full investigation report.
d)
An illness caused or mainly caused by exposures which occur during the employee's specifically
defined meal period or other specifically defined off-duty period would not be considered as caused or
mainly caused by exposures at work unless it concerned exposures to hazards specific to the work
area.
Example 1: Food poisoning which results from a meal furnished by the employer would be
considered an Occupational Illness.
Example 2: If, while eating in the same location as described in Example 1, an employee gets food
poisoning from his own supplied food, the case would not be considered an Occupational Illness.
36
PTS 60.0501
AUGUST 2010
Work related
Involved People, Asset or Environment
Control Influence
Location
RECORDABLE (OPU REPORTABLE) means that the incident is Recordable at PETRONAS reporting
level but Reportable at OPU and Business Unit reporting levels. Example 13, 14 and 16 below
explain the situations.
The following examples are intended to clarify the definition of Exposure Hours, and to give examples
where injuries are considered to be work related even though exposure hours are not being
accumulated at the time of the incident. Examples of identifying incident as either Reportable or
Recordable are also given.
Example 1:
Example 2:
Example 3:
An office worker living in a suburban area who travels to work by public transport.
This person's Exposure Hours would be the time spent at the office.
37
PTS 60.0501
Example 4:
An office worker living in a suburban area who travels to work in transport arranged by
the OPU/JV/HCU. This person's Exposure Hours would be the time spent at the office.
However, an Injury occurring to the employee in transport arranged by the
OPU/JV/HCU would be considered a work-related Injury.
Example 5:
Example 6:
Example 7:
An office employee working unscheduled extra hours. Whilst in theory such working
time should be treated as in Example 6, it is generally impracticable to keep records of
such working time and, hence, this person's Exposure Hours should be calculated on
the basis of the normal working week. However, an Injury occurring to the employee
during such overtime working would be considered a work-related Injury.
Example 8:
Example 9:
An employee is on the OPU/JV/HCU premise in his off duty time. Even if this time is
spent on OPU/JV/HCU premise, is not accumulated for the calculation of exposure
hours although incidents during this time shall be included if they are the results of
failure or absence of management controls.
Example 10: The employee deviates from a reasonably direct route of travel (side trip for vacation
or other personal reasons). This is not work related. But he would be again be in the
course of employment when he returned to the normal route of travel and Example 5
should apply if travelling time is outside the employees normal working hours.
Example 11: A truck driver, on his way to deliver product, deviates his route to go home / rest area
for lunch / dinner or stay overnight. On the way to that location, he was hijacked /
robbed. This is recordable and not work-related but the driver is subject to disciplinary
/ security action.
Example 12: PETRONAS OPU-A is delivering products / materials to PETRONAS OPU-B using
road transportation. A road accident occurs inside PETRONAS OPU-B compound.
This incident is work-related and the incident owner is PETRONAS OPU-B.
Example 13: An employee from PETRONAS OPU-A attends a training at PETRONAS OPU-B. An
incident happens at PETRONAS OPU-B involving the employee from PETRONAS
OPU-A. This is work-related. Since PETRONAS OPU-B has the control, the incident is
reportable for PETRONAS OPU-B. It is recordable for PETRONAS OPU-A.
Example 14: PETRONAS OPU-A1 NGV tanker was on its way for product delivery to a designated
location when it was hit from rear by another PETRONAS OPU-A2 tanker which is
hired by PETRONAS OPU-B for diesel delivery to a petrol station. The incident is work
related and reportable for PETRONAS OPU-B. It is also reportable for PETRONAS
OPU-A2 at the OPU level. The incident is recordable for PETRONAS OPU-A1.
Example 15: A PETRONAS OPU-A employee attended a meeting with PETRONAS OPU-B at
PETRONAS OPU-Bs site. PETRONAS OPU-A employee suffered an injury in a road
accident in a vehicle provided by PETRONAS OPU-B and driven by PETRONAS
OPU-B driver. Either the accident occurs inside PETRONAS OPU-Bs site or during on
the way to hotel / accommodation after the meeting / for lunch or dinner, the incident is
38
PTS 60.0501
AUGUST 2010
All incident cases involving Restricted Work Case or worse shall seek consultation from Group
HSE Division. Group HSE Division shall review the classification assigned by OPU/JV/HCUs.
In case where the Reportable and/or Recordable classifications are not clearly or easily
determined, or even disputable, the final decision falls under Group HSE Division.
39
PTS 60.0501
AUGUST 2010
Treatment of infection
Application of antiseptics during second or subsequent visit to medical personnel
Treatment of second or third degree burn(s)
Application of sutures (stitches)
Application of butterfly adhesive dressing(s) or sterile strip(s) in lieu of sutures
Removal of foreign bodies embedded in eye
Removal of foreign bodies from wound; if the procedure is complicated because of depth of
embedment, size, or location
Use of prescription medications (except a single dose administered on the first visit for minor
injury or discomfort)
Use of hot or cold soaking therapy during the second or subsequent visit to medical personnel
Application of hot or cold compress(es) during the second or subsequent visit to medical
personnel
Cutting away dead skin (surgical debridement)
Application of heat therapy during the second or subsequent visit to medical personnel
Use of whirlpool bath therapy during the second or subsequent visit to medical personnel
Positive X-ray diagnosis (fractures, broken bones, etc.)
Admission to a hospital or equivalent medical facility for treatment or observation for more than 12
hours.
Administration of tetanus shot(s) or booster(s). However, these shots are often given in
conjunction with more serious injuries. Consequently, injuries requiring these shots may be
included in the statistics for other reasons.
Diagnostic procedures, such as X-ray or laboratory analysis, unless they lead to further treatment.
LOSS OF CONSCIOUSNESS
If an employee loses consciousness as the result of a work-related Injury, the case must be reported
as at least an MTC no matter what type of treatment was provided. The rationale behind this is that
loss of consciousness is generally associated with the more serious injuries.
FIRST AID CASES (FAC)
The following examples are generally considered first aid treatment, i.e. one-off treatment and
subsequent observation of minor injuries:
40
PTS 60.0501
AUGUST 2010
41
PTS 60.0501
AUGUST 2010
Rating
Minor
Slight injury or health effects (resulting in First Aid Case) - Not affecting
work performance or causing disability.
Major
Description
ASSET DAMAGE
Class
Minor
Rating
1
2
Major
3
42
PTS 60.0501
AUGUST 2010
ENVIRONMENTAL EFFECT
Class
Rating
Description
Minor
Slight Effect
Leak/Spill contained within the secondary containment and
does not reach water and soil, and minimal volatilization to atmosphere
causing negligible impact to local environment
Minor Effect
Spill/leak contained within secondary containment causing
volatilization to atmosphere
limited contamination of soil or water within the containment area
non-permanent impacts to the environment
Emission/discharge exceeding company limit (where available) but within
legislative limit
Major
Local Effect
Spill/leak spreading outside the secondary containment but remain within
facility perimeter (for onshore operation) ** , causing limited soil/water
contamination OR resulting in Potential Consequence A, B or C below
Emission/discharges exceeding legislative limit OR resulting in Potential
Consequence A below
Potential Consequence
A) Cumulative and/or delayed environmental impact
B) Recovery < 1 month
C) Rehabilitation < 6 months
** For offshore operation, spill/leak into marine environment but limited potential
of contamination to the marine water
Major Effect
Spill/leak spreading outside the facility perimeter, managed to be recovered
but causing major contamination OR resulting in Potential Consequence
A, B or C below
Emission/discharges exceeding legislative limit with possible prosecution OR
resulting in Potential Consequence A below
Potential Consequence
A) Immediate impact with serious environmental damage
B) Recovery 1- 3 month
C) Rehabilitation 6 12 months
Massive Effect
Spill/leak spreading outside the facility perimeter, causing
massive
contamination OR resulting in Potential Consequence A, B or C below
Emission/discharges resulting in legal prosecution with possible total shutdown
of facility, OR resulting in Potential Consequence A below
Potential Consequence
A) Immediate impact with severe environmental damage
B) Recovery > 3 months
C) Rehabilitation > 12 months
43
PTS 60.0501
AUGUST 2010
IMPACT ON REPUTATION
Class
Minor
Rating
1
2
Major
Description
Slight impact - Public awareness may exist, but there is no public concern.
Limited impact - Some local public concern. Some local media and/or local
political attention with potentially adverse aspects for company operations.
Considerable impact - Regional public concern. Extensive adverse
attention in local media. Slight national media and / or local / regional political
attention. Adverse stance of local government and/or action groups.
SECURITY BREACH
Class
Minor
Rating
1
2
Major
Description
Slight impact
- Trespassing
- Theft/Buglary
Minor impact
- Minor criminal case inside companys premise
- Community disturbances
- Civil strife not affecting operation
- Armed robbery
- Criminal incident which causes public concern
Major impact
- Major criminal case resulting in injury
- Political/Civil strife affecting operation
- Arson
Serious impact
- Major criminal case resulting in single fatality
- OPU Internal or Labour Unrest
- Kidnapping
- Hostage situation or death threat inside companys premise
Extensive impact
- Major criminal case resulting in multiple fatalities
- Acts of terrorism involving the companys asset or operations
- Bomb threat, Sabotage
44
PTS 60.0501
AUGUST 2010
Rating
1
2
Timing
Within 24 hours
Reporting to Who
- OPU Internal Management
- Authority (if required)
-COMCEN
Major
Within 24 hours
- Head GHSED
- Respective VP & EVP
- Country Manager for
International Operation
In addition to:
- OPU Internal Management
- Authority
Within 1 hour
- COMCEN
- Presidents Office
5
Within 1 hour
Activation of Tier 2 and Tier 3 Emergency Response should be notified within 1 hour as per PTS
60.0112 Group Contingency Planning Standard.
The attached Initial Incident Notification form which is a minor update to a similar form found in PTS
60.0112 Group Contingency Planning Standard, should supersede any previous Initial Incident
Notification form.
45
PTS 60.0501
AUGUST 2010
OPU:
Tel:
INCIDENT NOTIFICATION FORM
Fax:
President (President Office) Business Head (EVP) Others:__________
COMCEN To Notify:
Respective VP
Tel:+603-2331 2141/42/43 GHSED
Legal
CSD
Fax:+603-2161 1696
Corporate Affairs
Country Manager
GRMU
IBU
Incident Location:
Incident Date:
Onshore:
Incident Time:
Offshore:
Department Responsible:
Process Incident
Date Prepared:
Time Prepared:
Direct Cause:
Activity Involved:
Sub-Direct Cause:
INCIDENT POTENTIAL
Incident terminated at __________ hrs.
Incident Under Control.
Incident currently not under control, but can be handled with available resources.
Incident will require additional resources (e.g., authorities, contractors, mutual aid).
Incident will likely generate significant public affairs/community, authorities relations issues.
ACTUAL IMPACTS
Life
Public
Environment
Land
Property
Water
Operations
Business and Reputation
Exact Location: _________________________
CASUALTY / FATALITY
Fatality No. : _____ Injury No. _____
rd
Prepared/Reported by:
Designation:
Designation:
46
PTS 60.0501
AUGUST 2010
EXPOSURE/CONTACT
STRUCK
CAUGHT
ENERGY
FALL
INTEGRITY FAILURE
ERGONOMIC
ASPHYXIATION
10
11
ILLNESS
LOSS OF CONTAINMENT
12
BIOLOGICAL
13
CRIME
14
NATURE
1
2
3
4
5
Flood
Earthquake
Tsunami
Landslide
Strong Wind / Tornado / Hurricane
47
PTS 60.0501
AUGUST 2010
EXPOSURE
Over a period of time, someone is exposed to harmful conditions.
Example:
A person is exposed to levels of noise in excess of 90 dBA for 8 hours.
Other examples are inhalation of fume, and exposure to radioactive.
CONTACT BY
Contact by a substance or material that by its very nature is harmful and causes injury.
Example:
A person is exposed by steam escaping from a pipe.
CONTACT-WITH
A person comes in contact with a harmful material. The person initiates the contact.
Example:
A person touches the hot surface of a boiler.
Other examples: Skin contact with chemical. Contact with hot/cold surface. Liquid (chemical, hot
water, condensate, steam) Splash.
STRUCK-BY
A person is forcefully struck by an object. The force of contact is provided by the object.
Example:
A pedestrian is struck by a moving vehicle.
Other examples: Hit by falling object, Cut by Object.
STRUCK-AGAINST
A person forcefully strikes an object. The person provides the force.
Example:
A person strikes a leg on a protruding beam.
Other examples: Person hits object. Walking into object.
CAUGHT-ON
A person or part of his/her clothing or equipment is caught on an object that is either moving or
stationary. This may cause the person to lose his/her balance and fall, be pulled into a machine, or
suffer some other harm.
Example:
A person snags a sleeve on the end of a hand rail.
CAUGHT-BETWEEN
A person is crushed, pinched or otherwise caught between either a moving object and stationary
object or between two moving objects.
Example:
A persons finger is caught between a door and its casing.
CAUGHT-IN
A person or part of him/her is trapped, struck, or otherwise caught in an opening or closure. Example:
A persons foot is caught in a hole in the floor.
48
PTS 60.0501
AUGUST 2010
FALL-TO-BELOW
A person slips or trips and falls to a surface level below the one he/she is standing or walking on.
Example:
A person trips on a stairway and falls to the floor below.
FALL-TO-SURFACE
A person slips or trips and falls to the surface he/she is standing or walking on.
Example:
A person trips on debris in the walkway and falls.
EXERTION
Someone over-exerts or strains him or herself while doing a job.
Example:
A person lifts a heavy object; repeatedly flexes the wrist to move materials, and: a person twists the
torso to place materials on a table. Interaction with objects, materials, etc. is involved.
BODILY REACTION
Caused solely from stress imposed by free movement of the body or assumption of a strained or
unnatural body position. A leading source of injury.
Example:
A person bends or twists to reach a valve and strains back.
49
PTS 60.0501
AUGUST 2010
1.
Brief Description
Third Party
Contractor
Recordable)
PETRONAS
Direct
Cause
(Reportable/
Activity
Involved
Category
Classifi-cation
Rating
Consequence
Location
No
Details of Incident
Results/Consequences (max
20 words)?:
See Appendix 9 of PTS 60.0501. Fill in the items in Sub-Category. If none, please put Other
(to specify)
Fatality(x), PTD(x), PPD(x), LWC(x), RWC(x), MTC(x), FAC(x), Property Damage, Pollution,
Operational Interruption, Other (to specify)
PTD = Permanent Total Disability, PPD = Permanent Partial Disability, LWC = Lost Workday
Case, RWC = Restricted Workday Case,
MTC = Medical Treatment Case, FAC = First Aid Case,
(x) = number of people affected
50
PTS 60.0501
AUGUST 2010
Incident
Recommendations
While waiting for detailed investigation report, the following recommended actions or precautions
are to be observed when:
i)
ii)
iii)
iv)
51
PTS 60.0501
1.1
General
The notification of an incident triggers the start of the investigation process, which comprises
the consecutive stages as indicated in Figure 1.
1.2
Incident Classification
An incident may result in serious injuries, illness, damage, environmental impact or
alternatively have only minor consequences. Lessons to avoid re-occurrence can be gained
from all incidents. For incidents with minor consequences the potential severity can still be
very high. Investigation of those cases may reveal as much about the deficiencies in HSE
management as cases in which major injury resulted. In isolation, incidents with minor
consequences and minor potential severity may provide little learning, but the collection and
analysis of data from many such incidents show trends which may be used to identify
measures for improvement in the overall HSE performance.
When assessing the potential severity of an incident two parameters are combined:
1. potential injury/damage/environmental impact
2. level of exposure/frequency of occurrence. The investigation effort in terms of team
composition and depth of investigation should be based on actual and potential severity.
The Incident Classification Criteria Matrix (Appendix 6) which is actual consequence should
be used to classify all the incidents prior to the investigation. The matrix should be used to
define the initial classification of incidents and when the initial notification can be reported. It
should also be used to determine the types of investigation to be conducted.
APPOINTMENT OF INVESTIGATORS
2.1
General
The size and composition of an investigation team will depend on one or all of the following
factors:
departments involved
legal requirements
For many incidents the investigative skill and effort required may be within the capability of
one person, who, for minor incidents, could be the line supervisor.
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 the unaffected
52
PTS 60.0501
AUGUST 2010
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.
Investigation Kit such as torch light, measuring tape, camera, rope etc should be available.
2.2
2.3
Contractor Incidents
The responsibility for investigating contractor incidents lies with the relevant Contractor. It is
recommended that:
Irrespective of the contractual obligations of the Contractor, the contract holder remains
responsible for ensuring that reportable incidents are treated in accordance with the
PETRONAS Group Guidelines with respect to timing and completeness of reporting.
2.4
53
PTS 60.0501
AUGUST 2010
For rating 4-5 incidents, Business Head in consultation with GHSED shall appoint external
Investigation Team. The external team members shall be from other OPUs.
An OH Doctor should be involved in the investigation that is related to occupational illness.
OPU/JV/HCU should notify the Head and/or General Manager of Group HSE Division when
investigation is to be initiated via e-mail or other practical means. Group HSE Division should
respond within 24 hours to the request.
2.5
THE INVESTIGATION
3.1
to identify the root causes of the incident such that actions can be taken to prevent
recurrence of future incidents
to establish the facts surrounding the incident for use in relation to potential insurance
claims or litigation
This may necessitate review of aspects remote from the location and time of the Incident.
3.2
Timing
An investigation should be carried out as soon as possible after an incident, preferably within
24 hours as the quality of evidence can deteriorate rapidly with time, and delayed
investigations only add to the uncertainties surrounding the investigation.
3.3
Background Information
Appropriate background information should be obtained before visiting the incident location.
Such information could include:
54
PTS 60.0501
AUGUST 2010
MS requirements as appropriate
messages, directions etc., given from base/head office concerning the work.
Before proceeding out to the scene of the accident, the team leader will brief the team the
information available thus far relating to the incident in terms of the harm done and actions
taken. The team will draw up the preliminary Hazard Event Target (HET) diagram as a
guide for gathering information. Where the barriers and controls can be identified they should
be reflected to produce the preliminary core diagram in the investigation process
3.4
During the initial stages of every investigation, investigators should aim to gather and record
all the information which may be of interest in determining causes.
Investigators should keep an open mind and considering the full range of possibilities.
Checklists can be very useful in the early stages to keep the full range of enquiry in mind, but
they cannot cover all possible aspects of an investigation, neither can they follow all individual
leads back to basic causal factors. When checklists are used, their limitations should be
clearly understood. Make use of the core diagram to act as prompters on areas to look at,
effectiveness of which could have prevented the accident.
3.4.1
The objective of this stage of the investigation is to collect as much information as possible.
Figure 1 provides an overview of the investigation and analysis process.
The scope of an investigation can be divided into five areas:
people
environment
equipment
procedures
organisation
Conditions, actions or omissions for each of these may be identified, which could be factors
contributing to the incident or to subsequent injury, damage or loss.
A factor to consider during an investigation is recent change. In many cases it has been found
that some change occurred prior to an incident which, combining with other causal factors
already present, served to initiate the incident. Changes in personnel, organisation,
procedures, processes and equipment should be investigated, particularly the hand-over of
control and instructions, and the communication of information about the change to those who
needed to know.
The effect of work cycles and work related stress could have an impact on individuals'
performance prior to an incident.
The impact of social and domestic pressures related to individuals' behaviour should not be
55
PTS 60.0501
AUGUST 2010
overlooked.
The initial stages of an investigation normally focus on conditions and activities close to the
incident and only immediate causes are usually identified at this stage. However, the
conditions underlying these causes may also need investigating.
Information should be verified wherever possible. Statements made by different witnesses
may conflict and supporting evidence may be needed.
To ensure that all the facts are uncovered, the broad questions of "who?, what?, when?,
where?, why? and how?" should be asked.
After fact finding / information gathering it should be possible to:
give a precise description of the incident, its background, timing, and the events
leading to it
describe the weather conditions
describe the operations
identify the equipment in use, its capabilities and any failures
describe the locations of key personnel and their actions immediately before, during
and immediately after the incident
describe all pertinent instructions
identify energy flows that were not controlled
identify operational deviations, other defects or inappropriate use of resources and
equipment
identify changes of staff, procedures, equipment or processes that could have
contributed to the accident
identify shortfalls in relevant personnel skill levels
identify whether alcohol or drugs were contributory
identify what barriers in place did not work or should be in place but missing
identify the effectiveness of safety programmes
comment on response to an accident (first aid, rescue, shut-down, fire-fighting, etc.)
identify damage control and medical treatment actions taken to prevent worsening of
the situation and the condition of injured parties, particularly if disabling injuries or
death ensued
make an inventory of all the consequences of the incident (injury, damage and loss).
3.4.2
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. Similarly, witnesses'
statements can usually be better understood and verified if discussed at site. Witnesses
should be readily available to the investigation team. It is not possible to set rules on
"immobilising" equipment at a location, but as far as possible the site should be kept "as is"
until at least a preliminary investigation has taken place. However, rescue operations or the
presence of residual hazards and/or congestion may justify moving some of the equipment.
Local legislation may prescribe that for certain classes of incident, e.g. fatality or motor
vehicle accident, nothing may be moved without prior permission from the relevant
authorities.
56
PTS 60.0501
AUGUST 2010
Photographs paper or digital and/or video film will assist the investigation. However, local
authorities may restrict site access or impound equipment and in such circumstances it may
not always be possible to obtain photographic records. In these situations sketches should be
made.
The investigators should be looking for any conditions in the immediate environment which
could have contributed to the incident. Items to check include:
3.4.3
In many incidents components or equipment may be damaged, or have failed. In these cases,
it is best to lodge this equipment in a secure place pending more detailed analysis.
3.4.4
Conducting Interviews
People should be interviewed singly and be asked to go step-by-step through the events
surrounding the incident, describing both their own actions and the actions of others. An
interview is best conducted in an environment / surrounding comfortable to the witness. This
is often the place of work or area where breaks are taken.
The value of a witness's statement can be greatly influenced by the style 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. This requires patience and understanding. If the
investigation is a team effort, great care should be taken not to make a witness feel
intimidated by too many interviewers. Experience has shown that interviews can be effectively
conducted by a pair of interviewers with one listening and asking questions while the other
listens and takes notes, interjecting on new information offerred and if appropriate, the
witness could be accompanied by an independent "friend".
It should be remembered that an investigation team is often seen in a prosecuting role, and
there may be a reluctance to talk freely if people think they may incriminate themselves or
their colleagues. An investigator is not in a position to give immunity in return for evidence,
but must try to convince interviewees of the purpose of the investigation which is to
understand what went wrong and why, not who is to be blamed and the need for frankness.
At the end of an interview the discussion should be summarised to make sure that no
misunderstandings exist. A written record should be made of the interview and this should be
discussed with the witness to clarify any anomalies. Any anomaly in the statement or conflicts
with other evidence must be clarified.
57
PTS 60.0501
AUGUST 2010
3.4.5
Conflicting Evidence
It is not unusual for different witnesses to give different accounts of an incident. Human
memory can be unreliable and, even if not motivated by self-protection or other subjective
argument, one person's recollection of an incident can differ from another's in quite important
details. Investigators should note any significant differences in accounts of an event. Faced
with conflicting witnesses' statements, investigators should look for the similarities between
the statements and commonality with other evidence. The objective is to use the evidence to
understand the incident and not to prove the accuracy of individual statements, nor to
apportion blame.
3.4.8
As the investigation progresses, the investigator(s) should begin to identify the sequence of
events the core diagram and concentrate efforts on Identifying the failed barriers / controls
and the causal chain of events leading to the latent conditions that initiate it.
3.4.9
As the extent of physical factors involved in an incident becomes clear, the investigator(s)
should shift the emphasis of their investigation and questioning to the underlying causes and
to the reasons for peoples' actions. This will allow for ease of assessment when analysing the
incident.
4
58
PTS 60.0501
AUGUST 2010
4.1
General
The approach of tabulating events and then ordering them by date, time and place is an
essential stage in establishing the sequence of events towards the Hazard Event Target
(HET) diagram for the accident. Identifying the respective failed barriers / controls result in the
establishment of the core diagram.
4.2
ANALYSIS OF FINDINGS
The purpose of analysis is to establish the critical events and the underlying causes of the
incident such that corrective measures can be taken to prevent future incidents, and also to
understand the failures and weaknesses in management system that led to the incident. This
requires investigators to have a clear understanding of the cause and sequence of activities
and why one event or situation progressed to the next. It is recommended to carry out the
investigation and analysis concurrently, so that they can support and build on each other.
Many methods are available for analyzing the underlying causes of incidents, but some of
these do not recognize the concepts of latent (management) failures. Therefore, the use of
Tripod methodology to conduct analysis of HSE incidents especially for Major Incidents is
highly recommended.
Incident causation studies, particularly the Tripod research, clearly identify that an incident is
the end result of a chain of events. These can be identified at differing stages in the incident
causation sequence.
The incident investigation should not be restricted to the unsafe acts or active failures as this
will only conclude that human failures (driver, operator, drilling crew) caused the incident
("human error"). The Tripod theory has shown that unsafe acts do not occur in isolation but
are influenced by existing preconditions, which may originate from failures in the top level of
the organisation and line management. Such activities and decisions are removed in time and
place from the end-of-the-line operations, where the incidents occur. The so-called latent
failures may lie dormant within the system for a long time, and their adverse consequences
may only become evident when they combine with other factors to breach the system
defences. Detailed case studies reveal that latent rather than active failures are the
precursors of incidents. Tripod classifies these latent failures into General Failure Types
(GFTs) / Basic Risk Factors (BRFs).
Identifying and correcting these latent failures rather than merely correcting the active failures
induced by them (symptoms), is more effective in meeting the ultimate objective of the
investigation, namely to improve the overall HSE performance.
Identification of underlying causes and latent failures need not necessarily involve application
of the full Tripod methodology, but should apply the causation theory as proposed by Tripod
(See Fig. 2), involving a brief consideration of the GFT/BRFs.
See Appendix 12 for a summary of the Tripod methodology.
59
PTS 60.0501
AUGUST 2010
For the investigation and analysis of less serious incidents or Minor Incidents, other
methodology other than Tripod can be used but should include an analysis of factors such as
type of incident, type of injury, phase of operation or activity, cause of incident which provide
valuable input to an incident prevention program.
In all findings, either using Tripod or other tools, the final analysis should be presented or
categorized into 11 Tripod Basic Risk Factors (BRF). This is important as to provide
consistent analysis to all the findings. The definitions of BRF are given in Appendix 13 and
the details can be referred to in PTS 60.0504 Tripod Beta The Analytical Tool (Guideline).
6
IDENTIFICATION OF RECOMMENDATIONS
The investigation process should identify actions to prevent recurrence. This can best be
achieved by addressing the unsafe acts and unsafe conditions, and by identifying and
correcting the latent failures.
Not all causes can be completely eliminated, and some may be eliminated only at prohibitive
cost. Some recommendations will therefore be aimed at reducing the risk to a tolerable level,
while others will be aimed at improving protective systems (the defences) to limit the
consequences.
All recommendations should be in the form of measurable action items with clearly defined
action parties and a time scale for implementation.
INVESTIGATION REPORT
7.1
Compilation
The investigation report is a presentation of the findings and recommendations of the
investigation team. The report should be in a standard form (see Appendix 14). For more
complex incidents diagrams of the Incident Investigation Trees should be attached to give an
overview of the causation sequence (see Appendix 12).
Appendix 14 provides an outline of an investigation report.
7.2
Legal Assistance
When incident reports are being compiled that may be required by authorities outside the
company, it is strongly recommended that legal advice is sought in the preparation of the
report. Legal advice should also be considered if third parties, including other authorities than
60
PTS 60.0501
AUGUST 2010
those directly competent in respect of the incident, request to be provided with copies of the
report. Each such request should be considered on a case by case basis taking into
consideration the potential risks and exposures for the Company, its directors and employees
for possible criminal or civil liability.
7.3
DATA RECORDING
Key data from all incidents should be registered in a database to facilitate
61
PTS 60.0501
AUGUST 2010
An "event" could be the start of a condition, e.g. a joint failure having created a flammable
atmosphere.
Not all of the events and the conditions described are faults. The full description of the circumstances
of an incident must include all normal factors so that decisions made and actions taken can be seen in
their correct context.
1.
CONSTRUCTION OF TREES
The incident event is the starting-point for constructing an investigation tree. Starting with the
incident itself, identify the prior events or conditions which were necessary for the incident to
happen (essential factors). Each factor can then be traced back in a similar way, identifying
further essential factors. The process of tracing back should be continued for each chain of
events to a point where it is considered to be outside the control or prevailing influence of the
Company.
Validation should establish that only factors which had any bearing on the incident are
included in the tree diagram. "Factors A, B (and C) were all necessary for event D to happen".
These should be joined by an 'and' gate. If removal of a factor is seen not to affect the
outcome it cannot be considered an essential factor.
If several alternative factors could have contributed to the next event, then these should be
combined through an "or" gate and may highlight an area where further investigation is
required.
An ongoing condition can appear more than once in an investigation tree, as a contributory
factor to events separate in time.
Care should be taken to describe facts correctly. For example, "failure to wear protective
equipment" may imply that there was a rule which was broken. Leads to follow from this fact
would be in the areas of supervision and motivation. The statement "no rule for wearing
protective equipment" would lead to areas of policy and procedures.
From the finished tree it should be possible to see where the operation deviated from its
desired course, and identify not only the specific actions of people involved but also areas of
weakness in a company's safety management.
The example below shows an investigation tree identifying remaining leads to be followed.
62
PTS 60.0501
AUGUST 2010
2.
63
PTS 60.0501
AUGUST 2010
4.
by main Contractor
by the Company.
64
PTS 60.0501
AUGUST 2010
65
PTS 60.0501
Short
Definition
Design
Single Sentence
Definition
Full Definition
HW
Hardware
PR
Procedures
A clear, formal
description of tasks to
be undertaken at the
operating interface
between people and
equipment
Popular
(Colloquial)
Definition
Applying
common sense
to equipment
and machinery
control layout
and positioning!
Or
Remembering
that equipment
and machinery
control layout
and positioning
has to be used
by human
beings!
Is the bit of kit
right for the job?
In the ideal
world, a
foolproof,
competent
persons guide
to the job.
Error Enforcing
Conditions
Conditions,
circumstances and
situations which will
significantly increase
the chance that errors
or violations will occur.
Flying by the
seat of your
pants is not the
best method of
dealing with
unexpected
problems or
opportunities
House Keeping
The maintenance of a
clean and tidy
workplace
66
A place for
everything and
everything in its
place.
PTS 60.0501
AUGUST 2010
TR
Training
Provision of
appropriate instruction
to develop
competence to enable
everyone to carry out
their jobs safely to the
required standard.
IG
Incompatible
Goals
Keeping on the
tightrope when
different weights
keep getting
added to your
balancing pole.
Communication
Providing the
right information
to the right
person at the
right time.
Organisation
67
PTS 60.0501
AUGUST 2010
MM
business
overlooked.
Maintenance
Management
Systematised
management to
ensure correct
maintenance of
processes, plant,
equipment and tools
Defences
Mitigation of the
consequences of
human and/or
technical failure
DF
68
1)
Detection/warning
2)
3)
4)
Escape
Recognising
that prevention
is better than
cure
The Last
Chance Saloon
- defences
should only
become active
in the last
stages before
an accident
occurs.
PTS 60.0501
AUGUST 2010
where events or conditions are listed, that are not critical for the incident to have occurred,
this should be clearly indicated
the report should be readable as a stand alone document, references to other documents not
open to inspection by others i.e. the public, should be avoided
a paper trail of the documents relevant to the incident and the report should be established.
14.1
69
PTS 60.0501
AUGUST 2010
Sequence of events
Impact of incident
Actual impact on people, asset, environment, reputation
Results of the incident investigation
This section should demonstrate that the investigation was carried out in sufficient depth to
support the conclusions that follow. It should include, where relevant, references to:
environmental conditions
condition of equipment and facilities, known deficiencies, positioning, operating mode,
etc
procedures relating to the operation
pertinent information concerning the principal operators and supervisors (e.g. training,
experience,
hours into shift and days into tour)
work instructions and communications
records and documentation
information derived from the nature of the damage
witnesses' statements
medical information (state of health)
factors affecting alertness or judgement (e.g. fatigue, social pressures, alcohol,
medication or drugs)
working conditions
survival aspects
results of special investigations and tests
rescue and damage containment activities
emergency response and recovery activities
Conclusions
This section should include the results of the analysis of the findings, identifying the
immediate and underlying causes and commenting on the effectiveness of rescue and
damage containment activities where appropriate.
Conclusions based on circumstantial evidence should be highlighted as such.
The underlying causes or root causes should be presented based on 11 BRF.
70
PTS 60.0501
AUGUST 2010
71
PTS 60.0501
AUGUST 2010
For MINOR INCIDENT, the following Incident Investigation Report should be used.
MINOR INCIDENT INVESTIGATION REPORT
Team Members
Leader
:
Member(s)
: (1)
: (2)
: (3)
Report Status:
OPU:
DIV:
Incidents Location:
Incident Date:
Incident Time:
Initial
Final
General Information
Reporter
:
Designation
:
Department
:
Immediate Supervisor:
Company Incident
Contractor Incident
rd
3 Party / Public
Reportable
Recordable
Authorities Informed
Police
Fire Department
DOE
DOSH
Others; Please specify:
1.0 Nature of Incident
Environmental Non-Compliance
Waste disposal
Effluent spill
Emission to Air
Discharge oil/chemical
Volume released
:
Volume recovered
:
Activity Involved :
No. of fatality:
No. of injury:
No. of hospitalized:
Workday lost: day(s)
Restricted Work Case
Medical Treatment
First Aid
Occupational Illness
2.0 Description of Incident: What, When, Where, Who, Why, How. Additional space for
description / sketches on Attachment page
72
PTS 60.0501
AUGUST 2010
OPU:
DIV:
5.0 Root Cause: Inadequate procedures, program, training, communication.(11 Tripod BRFs)
Person In-Charged:
7.0 Permanent Corrective Action:
Person In-Charged:
8.0 Management Control Action:
Person In-Charged:
Name
Date
Prepared by:
Reviewed by:
Approved &
Submitted by:
73
PTS 60.0501
AUGUST 2010
74
PTS 60.0501
AUGUST 2010
14.2
3. Incident Summary
Incident Details (What, Date & Time, Location, Impact, Immediate Action)
Investigation Team Members & Resource Person
4. Background
Background which may/ may not include photos or video
Details of casualty and/or victim (s)
5. Sequence of events
Times & events
6. Investigation Findings
Based on HSEMS elements & sub-elements
Causual tree / why-why
Tripod-Beta
7. Conclusion
Direct cause
Underlying cause (s)
8. Recommendation
Prioritize action plan
Time frame for action closure
Action parties
Report on closure status to Head, GHSED on quarterly basis
Action item to be tracked in iHSE
75
PTS 60.0501
AUGUST 2010
Are there any work-related exposures e.g. contact with hazardous substances, poor working
environment etc. which could have contributed to the death?
Are there any lifestyle factors e.g. diet, tobacco, alcohol abuse, etc.?
Has the individual been declared medically fit to carry out his/her normal duties in compliance
with OPU/JV/HCU standards?
Had the individual exhibited any signs or symptoms associated with the cause of death
before/during his/her recent work period?
Where death occurred within the OPU/JV/HCU fence, were the OPU/JV/HCU Medical
Emergency Response (including First Aid, Medical Treatment and Medevac) procedures
suitable and complied with?
76
PTS 60.0501
AUGUST 2010
b)
c)
d)
OCCUPATIONAL ILLNESS
An Occupational Illness is defined as 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 the exposure which caused the case, not by the resulting
condition of the affected employee. An Injury results from a single event or from a single
instantaneous exposure in the work environment. Cases resulting from anything other than a
single event or exposure are considered Occupational Illness.
The key performance indicator for Occupational Health incidents is Total Reportable
Occupational Illness Frequency (TROIF).
77
PTS 60.0501
AUGUST 2010
Examples to clarify the boundaries between Occupational and non-Occupational Illness, and
between Injury and Illness, are given in Appendix 2. Having determined that an illness is
occupational the Company should categorise it according to the classification in Appendix 5.
e)
ENVIRONMENTAL INCIDENTS
The definition of an Environmental Incident is "an unplanned event or chain of events that has
or could have a negative impact on the environment".
OPU/JV/HCUs are advised to develop its own specific guidance on the type and size of
spills and releases that would fall into consequence rating 4 or 5 of the Incident Classification
Criteria. Such guidance should take into account the specific environmental sensitivities in the
area of operation.
f)
REPUTATION INCIDENTS
The definition and classification of the severity follows the Incident Classification Criteria and
the reporting of such incidents is as Section 4. The requirement to mobilise the PETRONAS
Group Crisis Management Plan needs to be evaluated with reference to it.
OPU/JV/HCUs are advised to develop their own specific guidance on the type of Incidents
that could trigger adverse attention to the OPU/JV/HCUs operations and which would place it
into rating 4 or 5 of the Incident Classification Criteria. Such guidance should take into
account the specific local circumstances and sensitivities.
78
PTS 60.0501
AUGUST 2010