PSM-11 Incident Investigation

Injuries
Death and / or injury or occupational disease suffered by a person which arises out of and in the
course of his employment, on or off the employees' premises, i.e. resulting from work activity or
environment of employment.
Definition of employment is that all the work or activities performed in carrying out an assignment,
including incidental and related activities not covered by the assignment, voluntary work or activity
while on duty with the consent of the Company or for the purpose of benefiting the Company. Injuries
have been classified into 05 categories.
4.2.1 Fatality
Death resulting from a work injury or occupational illness.
4.2.2 Lost Workday Injury (LWI)
Any injury or illness which prevents the employee from performing all the duties of his regularly
assigned job on any workday following the incident on which the employee has been scheduled to
work.
4.2.3 Lost Workdays
All days (whether consecutive or not) on which an employee is scheduled to work, but is either absent
on restricted duty or unable to perform all the duties of his job because of injury or illness. Days away
from work should include only those full days or shifts that are missed by the employee / contractor.
No lost workdays are charged for fatalities.
4.2.4 Restricted Work Case (RWC)
Any work related injury that results in restricting the employee to perform all or any part of his
normal assignment during all or any part of the work day or shift.
Record ability of restricted duty at times will be dependent upon the nature of the work performed by
the employee. For example, a sprained ankle may not be 'Lost Workday' for an office assistant
working at a desk since he can perform all his duties but it probably would be for an operator,
mechanic or ware house man.
4.2.5 Medical Treatment Case (MTC)
Any work related injury in which treatment (other than first-aid) is administered by a physician or by
registered professional personnel under the standing orders of a physician.
Medical treatment does not include first-aid treatment, even though provided by a physician or
registered professional personnel.
Examples of Medical Treatment Case
Abrasions - Treatment of abrasions that occur to deeper than full skin depth.
Bruises - Treatment of a bruise by drainage of blood.
Burns - The treatments of second and third degree burns.
Casts - Application of a cast or other professional means of immobilizing an injured part of the body.
Debridement - Surgical Debridement, that is, the removal of dead or damaged skin.
Fractures - Treatment of fractures
Infections - Treatment of infections arising out of an injury.
Prescriptions - Administration of prescriptions medicines.
Sutures - The suturing (stitching of the edges) of any wound.
4.2.6 First-Aid Case (FAC)
First-aid is limited to any one-time treatment and any follow up visit for the purpose of observation of
minor scratches, cuts, burns, splinters and so forth, which do not ordinarily require prescription
medication / medical care. First aid can be provided by a physician or nurse. Surveillance or
observation, including overnight observation, which reveals no injury or illness shall be considered
first aid if the employee reports to his next regular schedule.
4.2.7 Reportable Injuries
All the following injuries to EPCL or contractor employees will be reportable:
1. Fatalities.
2. Lost Workday Injury (LWI).
3. Restricted Workday Case (RWC).
4. Medical Treatment Case (MTC).
5. First-Aid Case (FAC).
As per OSHA guidelines, injuries 1-4, as specified above are considered as recordable and used for
the calculation of Total Recordable Incidence Rate (TRIR). TRIR is calculated as follows:
TRIR = (No. of recordable injuries) x 200,000
(Man-hours)
Note: In some cases an injured or ill employee will miss one or more scheduled days or shifts beside
the day of injury or onset of illness, but it will be uncertain whether the employee was truly unable to
work on the days missed. Such cases may arise when physician judges that the employee is able to
work but the employee decides that he is not. In such cases, the supervisors / managers should not rely
solely on the physician's opinion. The manager of the employee can make the final judgment himself,
based on all the evidence at his disposal.
4.3 Occupational Illness
Occupational illness can be defined as any disorder not resulting from an injury that is caused by
environmental factors associated with employment. The basic difference between an injury or illness
is the single incident concept. If the conditions resulted from something that happened in one instance,
it is an injury. If the condition resulted from prolonged or multiple exposure to a hazardous substance
or environmental factor, it is an illness. A few examples of occupational illness are as under:
1. Un-authorized operation of radioactive source resulting in exposure of personnel to radiation with
adverse effects.
2. Drinking water tests for bacteria or other pollutants outside of specified limits.
3. Heat stress signs or symptoms of heat stroke or heat exhaustion.
4. Lead, asbestos or non-asbestos respirable fiber (NARF) material dispersed without preplanning.
5. Asbestos-containing materials (ACM) purchased or used when a technically feasible non-ACM is
available.
6. Storage of Personal Protective Equipment (PPE) that could result in chemicalexposure
(e.g., contaminated PPEs).
All diagnosed illnesses are considered medical treatment injuries if they are caused by work
exposures. All occupational illness including but not limited to the following categories are
recordable.
a) Occupational skin diseases or disorder - Examples: Contact dermatitis, eczema, or rash caused by
primary irritant and sensitizers or poisonous plants; oil acne; chrome ulcers; chemical burns or
inflammations; etc. (Direct contact causing tissue damage only, resulting from a thermal or chemical
burn, is classified as an injury, not an illness case).
b) Dust diseases of the lungs (pneumoconiosis) - Examples: Silicosis, asbestosis, coal workers
pneumoconiosis, byssionosis, and other pneumoconiosis.
c) Respiratory conditions due to Toxic Agents - Examples: Pneumonitic, pharyngits, rhinitis or acute
congestion due to chemicals, dusts, gases, or fumes, farmers lungs, etc.
d) Poisoning (systemic effects of Toxic Agents Materials) - Examples: Poisoning by lead, mercury,
cadmium arsenic, or other metals, poisoning by benzole, carbon monoxide, hydrogen sulfide or other
gases; poisoning by benzole, carbon tetrachloride, or other organize solvents; poisoning by insecticide
sprays such a parathion, lead arsenate; poisoning by other chemicals such as formaldehyde, plastics
and resins, etc.
e) Disorders due to physical agent (other than Toxic Materials) - Examples: Heatstroke, sun stroke,
heat exhaustion and other effects of environment heat; freezing, frostbite and effects of exposure to
low temperatures caisson disease; effects of ionizing radiation (isotopes, X-rays, radium), effects of
non-ionizing radiation (welding flash, ultraviolet rays, microwaves, subbrun), etc.
f) Disorder associated with Repeated Trauma - Examples: Noise-induced hearing loss; synovitis
tenosynovitis, and bursitis, and bursitis, Ray-nauds phenomena, and other conditions due to repeat
motion, vibration, or pressure.
g) All other Occupational Illness - Examples: Anthrax, brucellosis, infections hepatitis, malignant an
benign tumors, flood poisoning, histoplasmosis, coccidioidomy-cosis,etc.
h) While declaring an Occupational Illness the Doctor should thoroughly examine the case.
Occupational Illness can be reported after a week.
NOTE:
Conditions resulting from animal bites, such as insect or snakebites, or from one-time exposure to
chemicals are considered to be injuries.
4.4 Process Safety Incidents
Defined as an incident that directly involves or could involve, process equipment and materials,
including on-site storage and handling of process materials. It requires completion of Process Incident
Classification and Scoring Sheet (Section 12.2)
Additionally, incidents that result in any of the following offsite impacts are also classified as process
safety incidents: evacuation, shelter-in-place, injury / illness, or major media coverage.
4.4.1 Classification
Process incidents having scores of equal to or more than 75 points (>75 points) are classified as
Process Safety Incidents and require reporting and a formal incident report per Section 5.3 Process
Safety Incidents. Process Incidents having scores equal to or more than 130 points (> 130) are
classified as Serious Process Safety Incidents and necessitate investigation by a designated team.
Categories of Process Safety Incidents are as under:
4.4.2 Process Release
1. Any release of process materials in significant amount to the environment from manufacturing
facilities (leaks, relief valves discharging, etc.). Process vent gases released at safe locations will also
be reported. Some examples are:
- Significant release of flammable material such as VCM, hydrogen, methane, hot oil etc.
- Creation of a gas mixture or vapor cloud in the flammability limits in which ignition did not occur
but could possibly have occurred.
- Toxic gas or liquid release (VCM, EDC, and Chlorine) such as from valve gland, transmitter tubing,
transmitters etc. which required full face mask for isolation or caused panic in personnel working
downwind. (In case, prior information / proper coordination were carried out to vacate the downwind
area, then the incident will be an unsafe situation).
- Release or spills of corrosive or reactive materials.
- Weld, gaskets, flanges, packing, level glasses, vessel sheet or other failures Resulting in substantial
release of a hazardous material e.g. PVC, VCM Contaminated water, Chemicals, fereon gas,
hydrochloric acid, steam, sulphuric acid and caustic soda etc.
2. Any release of raw materials from transport trucks, railcars, etc.
3. Storage vessels overflow.
4. Piping system leaks (not to include fugitive emissions).
4.4.3 Fires
A fire is an unplanned combustion. An unplanned combustion is an event where there is
unplanned, visible smoke, visible flame, visible glowing or evidence of combustion (e.g., charring,
soot, motor burn etc.) which is not part of design basis (e.g., Flare, Hot vents etc.) and is not covered
by a valid work permit. Exception is given for fires at the fire training facility, controlled bush
burning in outlying areas and hot vents. Visible vapors due to evaporation of liquids e.g., lube oil
from oil console (designed for),
WD-40 sprayed on nuts / bolts during shutdown which evaporates as the surface gets hot in startup,
fading of paint from hot lines with aging etc. are exceptions to fire classification.
4.4.4 Inoperable Safety Equipment
1. Alarm or Interlock Trip Systems (this includes any component in the alarm or interlock circuitry)
that failed to activate or did not function as designed. This includes systems that fail during routine
operation or are discovered to be non-functional during the required periodic function test. e.g. . Flow
alarm low low (FALL), Temperature switch high (TSH) and Pressure switch low (PSL) etc. For
example, vibration securities on compressors, gas turbines and cooling towers, securities on
polymerizer lube oil pumps etc.
2. DCS / ESD / TDC failures resulting in loss of control on the operating parameters by
Operations staff.
3. Malfunctioning of emergency power generators.
4. Relief devices:
- Failed to open.
- Failed to reset. - Failed to open at the prescribed set pressure (PSV did not pop 1.5 times of the set
pressure) including PSD rupture below the set pressure.
- Devices (PSV, PSD, Safety Critical sensation line) plugged with process / foreign material.
- Inlet and / or exit piping plugged with process material.
5. Deluge Systems
- Failure of a system to function.
- Failure of a component in the system.
- Failure of a system to operate during the periodic function test.
6. Nonfunctioning safety equipment e.g., fire suppression system, smoke detector,
PPEs, alarms, extinguishers, safety showers / eye wash fountain etc.
4.4.5 Operational Upset
Any incident due to mal-operation or human error which has adverse effect on the plant operating
conditions e.g. temperature runaways, carry-overs or loss of normal operating conditions during
routine operations, startup, shutdown, preventive maintenance, repair jobs, housekeeping etc.
Some examples of Operational Upset are:
1. Runaway reaction.
2. Inadvertent closing / opening of isolating valves resulting in process upsets or plant shutdown e.g.,
closing of Cooling water XSV resulting in Fuel Gas Compressor shutdown.
3. PVC slurry carry over to RVCM circuit.
4. Upset in normal operation of unit (resulting in load reduction / shutdown due a mechanical /
electrical / instrumentation problem reason for which is found to be human error during maintenance).
4.4.6 Human Error
Given below are examples of certain incidents occurring due to human error which are also reportable
and fall in any of the incident categories described in this section.
1. Mal-operation resulting in upset of normal operating parameters causing emergency / abnormal
situation at the Plant e.g. slippage of Cations / Anions beyond control limits, selection of wrong
recipe.
2. Human error during preventive maintenance / repair jobs, housekeeping etc. which caused tripping
of an equipment or upset in plant operating conditions causing emergency situation at plant.
3. Shutdown of wrong electrical breaker.
4. Entering of old data, set points, control parameters on ESD, DCS resulting in rework after closure
of work permit.
4.4.7 Violation of Process Safety Management Systems
1. Facility changes implemented without executing required PSM Elements (examples Process
Safety Information, Training and Development, Management of Change, Pre-Startup Safety Review
etc.).
2. Incomplete installation of facilities.
3. Improper checkout of equipment.
4. Wrong installation.
5. Improper materials of construction.
6. Improper preparation of equipment for which a work permit has been issued which has a potential
for an accident or unauthorized change of conditions of the job under permit.
7. Job carried out without a valid work permit.
8. Procurement or use of a new chemical or mixture not reviewed by Sub-HSE (OHIH).
4.5 Violation of Safety Procedures / Practices
Violation of any safety standard or procedure. Some examples are:
1. Safety critical defeat form not filled while work is being done on the safety critical security.
2. Failure to follow established procedures, which could have resulted in injury or property damage.
3. Safety Harness not used at heights.
4. Faulty rigging equipment used which had a potential of accident
5. Substandard / wrongly certified scaffolding.
6. Noncompliance of work permits procedure.
7. Noncompliance of EPCL Policies (HSE, Driving, Smoking, Mobile etc.), Cardinal Rules, etc.
4.6 Vehicle Incidents (Cars, Trucks, Aerial Lifts, Derails, etc.)
1. On-site vehicle accidents.
2. Off-site vehicle incidents (Company or Resident Contractor on Company Business).
3. On-site vehicle fires (Company and Contractor).
4. Heavy equipment accidents (Cranes, Boom Trucks, etc.).
5. Crane operating unattended in the operating area with boom engaged or crane operating unattended
after return of permit.
4.7 Equipment Failure
Equipment that fails to function as designed and thus creates a safety concern. e.g.:
1. Failure of equipment which could have serious consequences. For example, Compressors piston
rod failures, damage to the cooling towers fans blades, damage of Poly agitator, rupture of exchanger
etc.
2. Hoists and Cranes that fail to function safely.
3. Gaskets / flanges / packing failure resulting in hazardous chemicals splashing around the area.
Some more examples are as under:
4.7.1 Intermixing of two or more process streams
1. Check valves failures resulting in intermixing of undesirable products.
2. Entering of Process streams into the utilities headers. For example, mixing of VCM, HCl, EDC,
Chlorine with utility headers e.g. polish water, condensate, plant air, steam, Cooling water, raw water
etc.
3. Miscellaneous carry over for e.g., mixing of Plant air in cooling water circuit, mixing of ion
exchange resin in steam condensate system etc.
4.7.2 Electrical Failures
1. Sparking / short circuiting in un-classified area but the breaker does not trip.
2. Sparking in classified area.
3. Breakers control power failures.
4. Errors in operation of electrical switches or equipment e.g., pump does not stop from local on / off
switch.
5. Inadvertent contact of mechanical equipment with un-insulated power lines. e.g. crane boom hitting
overhead power lines.
6. Short circuiting and / or electric shock to an employee.
4.8 Environmental Incident
Any incident which has an environmental impact outside EPCL property limits and leads to a formal
complaint will be considered as environmental incident e.g. EDC/ VCM/ Chlorine, HCl etc. (Details
are mentioned below), noise, effluent streams, NEQS excursion etc.
Moreover, following will also be declared as Environmental Incidents:
1. Release of any non-process material. e.g., fuel (gasoline, diesel, etc.)
2. Chemical spills in significant amount (see EPA guidelines) causing soil contamination.
3. Equipment leaking hydraulic oils etc.
4. Death of migratory birds in substantial number within plant operating area.
5. Death of any other wildlife that might have been caused by plant operations.
6. Death of any other wild life that has not been caused by plant operations should be used for
documentation only.
7. Death of animals or aquatic life in the canal cause for which is established to be plant effluent.
8. Waste water Stripper of (EDC/VCM and PVC) plant bypassed.
9. Hazardous gases (VCM,HCL, EDC, Ethylene, H2 & cl2) odor complain from outside EPCL site
boundary and concentration is reported 50% of TLV
10. Hazardous gases (VCM,HCL, EDC, Ethylene, H2 & cl2) odor complain from within the plan
boundary limit, roads, non-operating areas and concentration is more than 75% of TLV
11. Hazardous gases (VCM,HCL, EDC, Ethylene, H2 & cl2) concentration above TLV due to
unplanned activity that caused panic and concern for people working at plant
12. Outside complaint for any release / discharge of material that creates concern to general public
and surrounding communities e.g., foam carry over from cooling tower to surrounding communities
4.9 Others
1. Event with the potential to cause Injury / Illness, Chemical Exposure, etc. (Supervision will
exercise their judgment in making this call).
2. Furnace flameout, back fire or fire box explosion.
3. Mal-operation of major shop equipment.
4. Falling of a person from height without causing any injury.
5. Falling of objects from heights which could result in an injury.
6. Tripping of major equipment that do not have standby equipment or critical for smooth plant
operations e.g., Gas Turbine, Cooling tower fan, Fuel gas compressor, Poly discharge pump etc.
during normal operation and DEG while it is running in absence of GTG.
4.9.1 Repeat Incident
Incident to be classified as repeat if it happens at the same unit during same activity due to same cause
Note: Incident will be considered as a repeated incident if it is reoccurred within 12 months of its last
occurrence.
4.9.2 Ambiguous Cases
At times some incidents cannot be clearly classified based on the criteria / examples given in this
document. These incidents would be studied in detail by the Safety Section and based on this study,
would be classified. The members of this study group would be:
1. Safety Engineer. 2. Environment Engineer 3. OHIH Advisor
4. Safety Advisor.
5. HSE Manager.
The incident classification decision would be considered final based on this groups recommendation
and can only be changed by the Manufacturing HSE Chairman. Similarly in case of doubt, decision
for making a flyer / detailed report / investigation of an incident through a team by Safety Section
would be final.