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Incident Investigation Procedure

Procedure for Incident Investigation

Document Control Details

Document Issue Issue Date Compiled By Document

OwnerDuPont Consultant

Procedure For Incident

Investigation10th Feb.-09

Safety Rules & Procedures Sub-committee

Document Revision No. Revision Date Procedure Document No.

R-000 Nil P-006

User Notes: - Incident Investigation Sub Committee at Tata Power is the custodian of this document and is responsible for the Administration and Authorization of this Procedure. Incident Investigation Sub-Committee is responsible for confirming the accuracy and integrity of content and proposed changes to this procedure.

Controlled copy of the current version of this document is held at Corporate Safety Group, Tata Power and also available on Tata Power Portal “Sangam”. Any printed / electronic copy of this document is uncontrolled. It is recommended that users verify that the version being used by them is the current version by referring to the controlled version.

Document No.-P-006 Page 1 of 62 Rev. No. R-000


Table of Contents

Document Control Details.....................................................................................5

1. Introduction..................................................................................................6

1.1. Intent and Purpose........................................................................................6

2. Scope and field of application.......................................................................6

2.1. Scope.............................................................................................................8

2.2. Application....................................................................................................8

3. References.....................................................................................................9

4. Responsibilities.............................................................................................9

5. Definitions.....................................................................................................9

6. Investigation Process....................................................................................8

6.1. Initial Response and Reporting.....................................................................8

6.1.1 Initial Response.............................................................................................8

6.1.2..............................................................................................................Initial Reporting………………………………………………………………………………………………… 8

6.1.3. Classifying incidents....................................................................................8

6.1.4.........................................................................................Scoring of incidentsError! Bookmark not defined.

6.1.4.1......................................................................................Criteria for scoring ……………………………………………………………………………………….. 12

6.1.5 Initial Reporting Responsibilities and Time Limits:.......Error! Bookmark not defined.

6.2. Formation of Incident Investigating team............Error! Bookmark not defined.

6.3. Determining Facts...............................................Error! Bookmark not defined.

6.4. Determining Key Factors ..................................Error! Bookmark not defined.5

6.5. Determining the systems to be strengthened ....Error! Bookmark not defined.5

6.6. Recommending Corrective and Preventive Actions...........Error! Bookmark not defined.

6.7. Documenting and communicating the findings ....Error! Bookmark not defined.



6.7.1..............................................Documentation of Final Incident Investigation Report………………………………………… 15

6.7.2. Communication……………………………………………………………………………………………….. 16

6.8 Follow-up ..............................................................Error! Bookmark not defined.7

7. Government Agency Investigations.............................................................19

8. Management Systems..................................................................................19

8.1. Support resources.......................................................................................19

8.2. Management Records...........................................Error! Bookmark not defined.

8.3. Audit Requirements /Performance Metrics................................................19

8.4. Procedure Renewal Process........................................................................19

8.5. Deviation..............................................................Error! Bookmark not defined.

8.6. Training................................................................Error! Bookmark not defined.

8.7. Contact.................................................................Error! Bookmark not defined.

9. Annexures.............................................................Error! Bookmark not defined.

Annexure – A Definition......................................................................................18

Annexure – B Incident Investigation Flow Chart.........Error! Bookmark not defined.

Annexure – C Initial Incident Report – (Non – DINS) Formatt...........................24

Annexure – D Initial Incident Report – ( DINS) Format.......................................26

Annexure – E PFDE Incident scoring guidance .................................................27

Annexure – F Safety Area ownership details..............Error! Bookmark not defined.6

Annexure – G Criteria for deciding key factors...................................................23

Annexure – H PSM Elements identification guidelines.........4Error! Bookmark not defined.

Annexure – I Model Incident Ivestigation Report....Error! Bookmark not defined.4

Annexure – J Incident Investigation Report Format.........................................59

Annexure – K List of Toxic and hazardous chemicals.......................................63



Abbreviations CSG - Corporate sourcing group

DINS - Distribution Incidents

DISH - Director Industrial Safety & Health (also known as Factories Inspectorate in some States)

ED - Executive Director

ERT - Emergency Response Team

FAC - First Aid Case

HOD - Head of the Department

HR - Human Resources

IAQ - Indoor air quality

IIR - Initial Incident Report

IIRMS- Initial Incident Report Management System

IS - Indian Standards

ITS - Incident Tracking System

LWC - Lost Workday Case

MSD - Musculoskeletal disorder

MTC - Medical Treatment Case

NA -Not Applicable

NR -Not Required

OHS - Occupational Health Services

OTJ -Off the Job

PFDE -Process, Fire, Distribution and Environment

PM -Plant Manager

PPE - Personal Protective Equipment

PSM -Process Safety Management

RA -Responsibility and Accountability

RWC - Restricted Workday Case

SBU - Strategic Business Unit

SHE - Safety, Health and Environment

SI - Shift In-Charge

SPI - Serious Process Incident

SM - Site Manager

1. Introduction



Tata Power believe in conducting all its activities in a safe and environment friendly manner to avoid harm to employees, contractors, visitors and community.The ultimate goal of SHE management is to continuously reduce incidents and ultimately reach a target of zero. One important process that supports the drive towards this goal is the Reporting and Investigation of Incidents. It is essential that lessons are learnt from past incidents and measures are taken to prevent recurrence of incidents. Therefore, it is important that all incidents are reported and thorough investigations are carried out in a scientific manner to determine the key factors (physical, human and systems) that contributed to the incident so that corrective and preventive actions are taken for continual improvement of the SHE management system.

1.1. Intent and PurposeThis procedure is provided to effectively implement Tata Power Corporate Standard on “Incident Investigation, Classification and Reporting” and “Managing Occupational Injuries and Illnesses” at XXX site.

It is developed to outline the process for reporting, recording and investigating an incident, recommending corrective and preventive actions and to communicate the lessons learned to prevent recurrence of similar incidents.

The intent is to ensure that there is no ambiguity while reporting, classifying incidents, and injuries, illnesses, providing immediate response, medical assistance and investigation. It covers roles and responsibilities of all personnel associated with Incident Investigation as well as the methodology required to investigate effectively.

2. Scope and field of application2.1. Scope

This procedure is intended to provide a systematic, in-depth approach to the investigation of all incidents, including near misses, relating to occupational injuries and illnesses, process, fire, environment and distribution, with emphasis on the following management responsibilities:

Initial Response and Reporting Formation of the Investigation Team Determining Facts Determining the Key Factors Determining the Systems to be strengthened Recommending Corrective and Preventive Actions Documenting and Communicating the Findings Follow Up

2.2. ApplicationThis procedure shall apply to all incidents, including near misses, arising out of work related activities at the TATA POWER - XXX location involving company employees, contract employees, contractor employees and visitors.

However, all non-work related incidents involving company employees should also be reported to the site management by HOD for information and appropriate action but shall not be included in the site SHE performance records.



In addition, the concerned departments must also be aware of and follow any applicable regulatory requirements.

3. ReferencesTATA POWER: Incident Investigation StandardTATA POWER: Process, Fire, Distribution and Environmental Incident Classification and Reporting StandardTATA POWER: Managing Occupational Injuries and Illness Standard

If more clarifications are required while interpreting this procedure, the above standards are to be referred.

4. Responsibilities The following table defines the responsibilities of persons / Committees/Control centers in the Incident Investigation process.

All site personnel – employees, contract employees, contractor employees and visitors

Report all incidents, including near misses.

Hosts Ensure that all visitors understand that all incidents, including near misses, must be reported.

HOD Review the scoring of IIR Ensure that incidents and near misses are

investigated and a report is submitted within the defined time limit.

Ensure that all recommendations are implemented in time

HOD (Medical), Shift In Charge (OHC), HOD (Safety), HOD (Environment)

Support and advise the line manager with incident investigation, including classification and to provide medical assistance.

HOD (Medical) Monitor status of injured persons and liaise with outside hospitals

HOD (Safety) Custodian of the incident information retained in the IIRMS and ensures that the data is validated.

Ensure legal compliance and report incidents to regulatory authorities.

Head (SHE) Communicate incidents for learning across the organization.

HOD (HR) Liaise with DISH for workmen compensation

IISC Custodian of this document and is responsible for the Administration and Authorization of this Procedure

Central SHE Committee Review all significant and high potential incidents.

5. Definitions



Refer Annexure A

6. Investigation ProcessThe steps involved in the incident investigation procedure are show in a flow chart at Annexure – B and are detailed below:

6.1. Initial Response and Reporting

6.1.1. Initial ResponseWhen an incident occurs and comes to the knowledge of the shift engineer / shift in charge / area in charge / In-charge, Security Control Centre, he / she is to organize, whenever necessary:

Rescue of personnel / medical help Fire Fighting Preventive measures to mitigate the impact of the incident Preserve the incident site to the extent possible and collect physical, human

and systems evidence to the extent possible Inform management of the incident

6.1.2. Initial Reporting

Shift engineer / shift in charge / area in charge / officer on duty (for non plant areas), will generate the IIR in the IIRMS within 8 hours of the incident.

However, HOD may review the scoring within 24 hrs of the incident.Initial reports should be brief and limited to a brief outline of the known facts (date, time, place, what happened, and immediate actions taken. For the IIR format, refer Annexure C for non – DINS Incident and Annexure D for DINS Incident.

6.1.3. Classifying Incidents:

The first step in classification is to determine work relatedness. This is based on whether the injury or illness occurred while the individual was engaged in Tata Power work. Once it is decided that the injury or illness is work related, it must also be classified into severity categories that denote the impact of an injury or illness.

Lost workday cases (LWCs), restricted workday cases (RWCs), and medical treatment cases (MTCs) are Tata Power reportable cases and are tracked corporately as the lost workday case rate and the total reportable case rate (LWCs plus RWCs plus MTCs). First-aid cases (FACs) are neither TATA POWER reportable nor tracked corporately.

A. Tata Power reportable cases

Lost workday cases (LWC)



If an employee is unable to work on a subsequent scheduled shift because of a work related injury or illness‚ the case is classified as an LWC. The shift on which the case occurred is not counted as a lost workday.

Restricted workday cases (RWC)

An RWC is a case in which a work-related injury or illness prevents the employee from working a complete shift (or from doing any tasks that are part of his or her regularly scheduled job that may be performed or assigned) but which does not result in lost workdays.

Medical treatment cases (MTC) An MTC is a work-related case for which medical treatment is indicated but that does not result in lost work or work restrictions

B Tata Power non reportable cases

First-aid cases (FAC)

A minor injury that calls for only simple treatment and does not call for follow-up treatment by a health-care professional is an FAC. A case can be classified as an FAC even if a health-care professional administers the first aid.

Injuries classified as FACs are not TATA POWER reportable, but they should be managed and tracked at the site level. FACs however shall be reported to the Corporate SHE Group for Corporate Safety Database

The time limit and responsibilities for communicating incidents relating to occupational injuries and illnesses is as shown:

Sr.No Category /

Activity

By Whom To Whom Time

LimitBy

WhomTo

Whom Time Limit

1

Internal Communication External CommunicationNear Misses SI/Area

In-Charge

HOD, SM Depending on potential, not later than end of shift

NA NA NA

2

Injuries and occupational illnesses

SI/Area In-Charge

HOD, SM Immediate

NA NA NA

3 Work related fatalities

HOD Site (SHE), SM/Site Head, SBU Head

Immediate

Site (SHE)

Head, Corporate SHE

Within 2 hrs

SBU Head

ED ; Corpora

Within 2 hrs



te HRHOD (HR)

DISH Orally Within 2 hrs, in writing within 12 Hrs.

HOD (HR)

Police Within 2 hrs.

HOD (HR)

Family Members

Within 2 hrs.

4 LWC

SI/Area In-Charge

Site (SHE), SM/Site Head, SBU Head

Immediate

Site (SHE)

Head, Corporate SHE

Within24 Hrs

HOD (HR)

DISH/Factory Inspectorate

Within 48 hrs

5 RWC / MTCSI/Area In-Charge

Site (SHE), SM/Site Head

Within 24 hrs

Site (SHE)

Head, Corporate SHE

Within24 Hrs

6

Incidents deemed to have Major potential/Media Focus (only verbal communication)

SM/Site Head

SBU Head Immediate & Continuous updates

SBU Head

ED ; Corporate HR

Immediate and Continuous Updates

6.1.4.Scoring of incidents

Scoring will be required for all PFDE incidents only. If an incident results in injury or illness without PFDE, scoring is not applicable.

6.1.4.1. Criteria for Scoring:In determining the scoring for PFDE incidents take into account the following criteria. (All criteria may not be needed for every type of incident).

1. Hazards and materials involved2. Actual size of release/incident3. System inventory with the potential for release 4. Degree of control site had in the incident 5. Involvement of last-line-of-defense safety devices6. Actual on-site impact 7. Potential on-site impact 8. Actual off-site impact



9. Potential off-site impact 10.Actual monetary loss in equipment damage and lost revenue

The applicable criteria for the PFDE categories of incidents and the minimum/ maximum scores for each category are provided in the following table.

Process Fire (a) Distribution

(b) Environment (c)

Applicable criteria 1 to 10 1, 2, 3, 4, 6, 8,

10 1, 2, 8 1, 2, 6, 8

Minimum score 10 15 10 0

Maximum score 220 180 70 90

(a) If a fire initiating on a non-TATA POWER operation spreads to TATA POWER property or equipment, it shall be scored, classified, and reported as a TATA POWER fire.

(b) Meets “distribution incident” definition. (c) A score of 0 for all criteria means the incident should not be classified as an

environmental incident. Refer Annexure E for PFDE Incident scoring guidance, to determine the actual

scoring:

Based on the scoring obtained, the incidents are classified as shown below:

Type of

Incident

Classification score and automatic criteria

Process

SPI >130 points or automatic designation from criteria 6, 8,or 10

Process Incident

> or = 75 points

OPI (Other Process Incident)

< 75 points

Environment

Category A > 0r = 45 points or automatic designation from criterion 8

Category B 30–40 points

Category C 5–25 points

Fire

Category A Automatic designation from criteria 6, 8, or 10 Document No.-P-006 Page 11 of 62 Rev. No. R-

000


Category B > or = 45 points

Category C <45 points

Distribution

Category A Meets “distribution incident” definition and scores> or = 55 points or automatic designation from criterion 8

Category B Meets “distribution incident” definition and scores < 55 points

Category C DINS Category C incidents or prevention opportunities (see Section 5; do not score)

6.1.5 Initial Reporting Responsibilities and Time Limits:The responsibilities and time limits for communicating PFDE incidents are as shown below:

Sr.No Category /

Activity

By Whom To Whom Time Limit By

WhomTo

Whom

Time Limit

1

Internal Communication External Communication

Near Misses SI/Area In-Charge

HOD, SM Depending on potential, not later than end of shift

NA NA NA

2All incidents SI/Area

In-Charge

HOD, SM Immediate NA NA NA

3

Process Incidents, Category B: Environment, Fire & Distribution incidents

SI/Area In-Charge

HOD, SM As early as possible, but not later than 24 hours

SM/Site Head

APEX, ED

Within 72 Hrs

4

All SPIs, Category A: Environment, Fire & Distribution incidents

SI/Area In-Charge

HOD, SM Immediate SM/Site Head

APEX,ED

Within24 Hrs

5

Transmission & Distribution (T&D) and Off-site material handling Incidents

Station/Activity In Charge

SM/Site Head, HOD, Head SHE

As early as possible, but not later than 24 hours

SM/Site Head

APEX,ED

Within 24Hrs



6

Incidents deemed to have Major potential/Media Focus (only verbal communication)

SM/Site Head

Head, Corporate Communication

Immediate & Continuous updates

SM/Site Head

APEX,ED

Immediate & Continuous updates

7In case of Reclassification of PFDE Incidents

HOD Site (SHE) Before reclassification

Site (SHE)

Corporate SHE, APEX,ED

Before reclassification

6.2 Formation of Incident Investigating teamHOD is responsible for ensuring that all reported incidents are investigated.

Refer Annexure F for the list of Safety Area Ownership details.If the HOD, based on some valid reasons, decides that it is not necessary to conduct a formal investigation of an incident, such decision shall be clearly documented with reasons for not conducting a formal investigation and the Site Head’s approval obtained. Though a formal investigation was not done, the key learning’s and corrective actions to be taken should be part of this document. This approved document should be forwarded to the Head (SHE) and Chairman, IISC.For conducting a formal Incident Investigation, the line management (e.g., SM, PM, HOD) forms the Investigating Team within 24 hrs of the occurrence of the incident.

Based on scoring or nature of occupational injury/illness, either Site Head or HOD will form the team, as shown below:

Score Team FormationResponsibility

≥130 or Multiple LWC or Fatality Site Head≥ 75 < 130 or LWC HOD

< 75 or any occupational injury or illness below LWC

HOD

In determining the composition of the investigating team, the following guidelines need to be considered depending on the nature, severity and complexity of the incident:

The team should consist of a minimum six members. A person trained in RCFA is a must. A senior member of management from the area where the incident

occurred (typically he or she becomes the chairperson) Operation, Engineering and maintenance personnel An appropriate SHE member



Incident controller in case the incident was handled as an emergency A first-line supervisor from the affected area Individuals who have firsthand knowledge of the incident Research or technical personnel Another member of supervision from a location not involved in the

incident As appropriate, and where the incident involved contract work, contractor

management and employees Other specialists or consultants (e.g., Corporate/Site/Corporate SHE

Group, Fire Protection Group, Sourcing, Legal, External Affairs, or Medical Group)

Where fatalities or serious injuries have occurred, the Liaison person from the HR / IR department dealing with the family.

For major, traumatic events, including those involving death or serious injury, major property damage, or significant environmental impact, strong consideration should be given to participation by the Company / site PSM Coordinator, location SHE Chief, a member of Corporate Safety Group, consultants, or Legal.

Note: The above are only guidelines for team formation. It may not be necessary that all the above members are required for all incidents.

6.3 Determining FactsWhere applicable, the incident team should perform the following tasks as part of the fact-gathering phase of the investigation:

Sample spills, vapors, residues, and other relevant materials, noting conditions which may have affected the samples

Preserve an accurate depiction of the scene through photographs, videotape, field sketches, maps, and other graphic representations.

Obtain on-the-spot information from eyewitnesses. More extensive interviews from witnesses should be taken as quickly as possible. These interviews should be conducted individually and privately so that the comments of one witness do not influence those of another. Interviews should be individually documented and confirmed by the interviewee; if possible use audio or video recording.

Examine key mechanical equipment (where relevant, as it is disassembled).

Review all potential sources of useful information. These may include as-built drawings, operating logs, recorder charts, previous reports, procedures, equipment manuals, oral instructions, change of design records, design data, DCS data, employee training and performance records, computer simulations, and laboratory tests.

Seek inputs from key personnel like operator / supervisor Determine which incident-related items should be collected or

preserved. When preliminary investigation reveals that an item has been damaged or may have failed to operate correctly, the investigation team should ensure that the item is preserved in an “as-found” condition or that any subsequent repairs or modifications are documented. Where



applicable, the team should develop the chronology of events that occurred before, during, and after the incident based on the above and other information.

The focus of the chronology should be solely on what happened and what actions were taken. List alternative chronologies when the status cannot be definitely established because of missing or contradictory information. Note unconfirmed assumptions and take action to verify them.

List all known facts, not only related to incident significance, but pertinent background data, specifications, and recent past and/or external events that could have an influence on the overall system.

Identify conditions or circumstances that deviated from normal, no matter how insignificant they may seem:

The effect of work cycles and work related stress that could have an impact on individuals' performance prior to an incident.

The impact of social and domestic pressures related to individuals' behavior should not be overlooked.

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.

6.4 Determining Key factorsKey factors are those circumstances that may have contributed to the incident’s occurrence even though a clear logical connection cannot be found. These factors include physical, human and systems that are found to be deficient or otherwise capable of being improved.In addition, it is necessary to construct an Incident Investigation Tree (i.e. WHY Tree). This is rather like a flowchart showing the connections between the various events and conditions leading to the incident, using the questions such as:- What controls should have been in place to prevent this

incident?- What were the events or conditions that defeated these

controls?- What were the unsafe conditions or unsafe acts that led to this

situation?- Why did this happen?- What were the failures in the SHE Management System that

allowed this to happen?Guidelines for determining key factors are given in Annexure G

6.5 Determine Systems to be strengthened:The recommendations should identify the PSM elements that need to be strengthened. The guidelines are shown in Annexure H.

6.6 Recommending Corrective and Preventive Actions



Based on the key factors (Physical, Human and System) determined, recommended corrective and preventive actions should cover, as a minimum, the following:

A clear description of the recommended action(s) to be taken to prevent recurrence.

The name/position of the person responsible for implementation. A completion date.

NOTE: Recommendations that need to be completed before operations resume should be clearly identified. Other recommendations (e.g., longer-term system- related improvements or evaluations) often require a completion date that extends beyond startup.

6.7 Documentation & Communication of Findings6.7.1 Documentation of Final Incident Investigation Report: A model

Incident Investigation Report is given in Annexure I, which may be referred for proper documentation.

The Incident investigation report should be made in the format as prescribed in Annexure J. The report should be submitted by the team leader for the concurrence of the HOD within the time period as shown below:

Sr.No

Incident Type Time Limit To whom After concurrence it is released by HOD to

1. Process Incidents (Including SPI) and Category A and B Environment, Fire & Incidents resulting in LWC, RWC & MTC

Within 3 weeks of occurrence of the incident

HOD or Site Head, as the case may be

Within one week of receipt of report, but not later than 4 weeks of occurrence of the incident, whichever is earlier

Site Head, All HODs

2. Distribution Incidents


HODWithin one week of receipt of report, but not later than 6 weeks of occurrence of the incident, whichever is earlier

Site Head, All HODs

3. All other Incidents (including work related injury and illness)


HODWithin one week of receipt of report, but not later than 4 weeks of occurrence of the incident, whichever is earlier

Site Head, All HODs



6.7.2 CommunicationLesson learnt from the Incident Investigation shall be shared and discussed with appropriate personnel, including employees and contractors from the affected area, as well as those whose job tasks are related to the incident findings. Consideration should be given to communicating findings to other sites / location as appropriate. Suggested means of Communication:

Safety contacts. Tool-Box-Talks. E-mails. SHE Portal Notice boards. Focused campaigns. Plant rack-up meetings. Departmental meetings Case Study Workshop / Presentation

Sr.No

Type of Communication By To Time Limit

1. Internal – the communication note to be prepared by (site to decide)

HOD (SHE) All concerned employees

Within 72 hrs of receipt of investigation report

HOD (Purchase/CSG)

All concerned Contractor employees

Within a week of receipt of final report

HOD/Area In-Charge

All employees in his plant/dept

Within a week of receipt of final report (Discussion in detail)

2. External HOD (SHE) thru’ Site Manager & Head, SBU

Apex, Head Corporate SHE, DISH/Factory Inspectorate

Within 72 hrs of receipt of final report

6.8 Follow UpTo ensure prompt follow-up and closure of recommendations from an incident investigation report, a system must be developed for periodic status reports by HOD to Chairman –IISC/Head, SHE/Site Head until all recommendations are acted on and closed out.

Additionally, it must be ensured that the system includes a verification of the implementation and effectiveness of the corrective action. If a recommendation is to be declined, the HOD shall document, in writing and obtain the approval of Site Head based on adequate evidence, that one or more of the following conditions is true:

1. The analysis on which the recommendation is based contains material



factual errors.2. The recommendation is not necessary to protect the health and safety of

the employer’s own employees, the employees of contractors, or the health and safety of the community, wildlife, or environment.

3. An alternative measure would prevent recurrence of a similar incident. 4. The recommendation is not feasible (note that an alternative

recommendation should be provided to address the key factor). The investigation report can be finally closed only by HOD after due verification that all recommendations have been implemented.The documentation shall be retained for 5 years as part of the official record of the investigation.

7 Government agency investigations If municipal, state and national governmental agencies are investigating certain incidents that occurred at TATA POWER - XXX site, HOD, SHE shall coordinate and facilitate such investigation. On receiving information of any such investigation, he shall keep the HOD (HR); Site Head; Head, SBU and Head, Corporate SHE informed and thereafter proceed under appropriate guidance and direction from relevant agencies (including Legal). Because of the potential of such governmental investigations, TATA POWER - XXX’s own investigation team should take care not to contaminate or destroy evidence that might be of value to such governmental investigations. There must be no inference that TATA POWER has withheld pertinent facts or otherwise impeded the governmental investigation.

Requests by government agencies for access to the XXX’s investigation reports and related materials should be discussed with Site Head and Legal before they are honored.

8 Management Systems

8.1 Support resources

When requested by investigating team, the site SHE is to provide the necessary support as appropriate.

8.2 Audit Requirements /Performance MetricsIncident investigation is to be audited as part of the second-party SHE audit protocol every year. Chief (SHE) shall develop and track metrics for internal use (e.g., key factors or PSM elements).

8.3 Procedure Renewal Process

The procedure shall be reviewed and revised as necessary and, at a minimum, not later than 5 years from the date of the last revision by the IISC.

8.4 Deviation

Approval from Apex SHE Committee shall be obtained before deviating from this procedure. Any request for deviation from the procedures shall be supported by appropriate reasons and shall be documented.

8.5 TrainingDocument No.-P-006 Page 18 of 62 Rev. No. R-

000


Training for investigating the incident using “WHY TREE” analysis, to understand investigation procedures and to familiarize the scoring/ classification system is to be given to all staff expected to be involved in the incident investigation team. Safety Training Sub Committee is responsible for organizing the training.

8.6 ContactAny Clarification/Interpretation regarding this procedure shall be referred to the Chairman, Corporate IISC.

9.0 Annexure:



Annexure – A Definitions

Accountability metrics — An injury or illness that is reported and tracked as a measure of organizational SHE performance.

Aggravate — Make a pre-existing condition more severe. Area In-Charge – Person responsible for specified area in a Project Site where

incident occurs. Examples of specified areas are Boiler Area, Turbine Area, Cooling Tower Area, DM Plant Area etc.

Contract employee — A person who has entered into a contractual relationship directly with TATA POWER

Contractor - Any non – TATA POWER entity that provides good and/or services described in a contract for TATA POWER.

Contractor employee — A person employed by a contractor to carry out work under the terms of a contract.

Deputed Employee – An employee temporarily assigned for a fixed duration to a business or organization (including non – TATA POWER) other than his or her normal one.

Distribution— i) Transmission and Distribution of Power from generating station to receiving/distribution stations and to final consumer, ii) Transportation of materials like fuels, ash, equipment/machines.

Distribution incidents (DINS) — An incident occurring during the distribution/transmission/transportation of energy/materials under TATA POWER control.

Environmental incident — A distinct spill, leak, or release of a chemical or chemical mixture to the environment.

Fire — An unplanned combustion. This includes electrical arcs that also involve a subsequent fire or evidence of combustion. Evidence of combustion includes flames, smoke, or charring.

First-aid treatment — Simple treatment given to a person with a minor injury that does not call for follow-up treatment by a health-care professional.

Hazard— An agent (chemical, physical, or biological) that has the potential to cause injury or illness.

Health— A state of complete physical, mental, and social well-being. In the working environment, there are two aspects: the effects of work on health and the effects of health on work.

Health-care professional - any licensed, registered, or certified health-care provider working within his or her license, registration, or certification and providing medical services (e.g., physicians, physician assistants, nurse practitioners, and registered nurses).

Human Resources (HR) — The function that assists line management with recruiting and maintaining personnel, implementing practices for consistent and equitable treatment of people, and maintaining a healthy and productive work environment.

Indoor Air Quality - the condition of ambient air in a workspace.



Investigation team — A group, normally led by line management, with representation or input from the affected individual(s), and safety, OHS, ergonomic, HR, risk management, or other specialists.

Incident / SHE Incident - An unplanned or an unusual event or a series of events and circumstances that resulted in or had the potential that could result in, an adverse or undesirable safety, health, fire and environmental consequence. Undesirable consequences related to SHE incidents include, but are not limited to the following:

Injuries and Occupational illnesses Process Safety Environmental Release Property damage Fire Business interruption Unfavorable impact on the public Adverse community reaction Damage to Reputation

Key factors— Circumstances that contributed to or may be reasonably believed to have contributed to the incident’s occurrence even though a clear causal connection cannot be found. These factors include physical, human, equipment, or systems that are found to be deficient or otherwise capable of being improved.

Location - Location includes manufacturing and non manufacturing facilities, joint ventures in which Company has majority ownership, and dedicated off-site contractor operations.

Medical treatment — Medication or treatment that is normally administered by a health-care professional and that goes beyond first-aid treatment.

Musculoskeletal disorder (MSD) — A disorder of the muscles, tendons, nerves, or vascular (blood supply system) structures. MSDs may be caused, precipitated, or aggravated by exposure to ergonomically related risk factors and include such disorders as carpal tunnel syndrome, tendonitis, epicondylitis, and bursitis

Not preventable by TATA POWER—injuries/illnesses caused by events external to the control or responsibility of TATA POWER (e.g., a traffic accident where the injured party could not have prevented it, an airplane crash, a fume release from a neighbouring non- TATA POWER , or an explosion at a nearby non- TATA POWER that propels debris onto TATA POWER property).

Occupational illness—a health condition caused by, precipitated by, contributed to, or aggravated by exposure to workplace hazards over a period of time.

Occupational injury – a physical condition that results from an incident or a single, brief exposure in the workplace (e.g., burn, laceration or fracture).

Occupational Health Services (OHS) — Medical, wellness, and other health-related services provided by TATA POWER health-care professionals.

Prevention opportunity — An occurrence related to distribution that results in, or might have resulted in, personal injury, damage to property, product release, fire, explosion, media coverage, or major inconvenience to the public,



but that does not meet the definition of a distribution incident. This shall also be termed as ‘DINS Category C incident’.

Process incident—an incident that directly involves or could involve process equipment and materials, including on-site storage and handling of process materials, and scores 75 points or more using the scoring system described in Annexure E, including any incident classified as an automatic SPI. Note: Personnel safety incidents (e.g., slips; trips; falls; being hit, struck, or crushed by non process equipment; and hand lacerations involving TATA POWER and/or non-TATA POWER employees associated with either non process equipment or process equipment that is not operating/in use) are not considered process incidents.

Public area - parts of a site that are outside the secured area and accessible to the public(e.g., credit unions, social or recreation facilities, and common cafeterias, banks, and shops). Public areas also include access roads and walkways related to any of these facilities.

Reportable - describes an injury or illness that is reported to Company corporate and/or regulatory authorities.

Restricted work activity - Limitations on work activity that prevent an individual from doing any task of his or her normal job or from doing the entire job for any part of the day.

TATA POWER Corporate Safety Database: The corporate incident tracking system (ITS) maintained by the Corporate SHE Group as a record of injuries and illnesses.

TATA POWER Employee: an individual employed by TATA POWER or a majority-owned subsidiary or joint venture.

TATA POWER premises - buildings, parts of multi-tenant buildings, plants, farms, parking lots and access roads, and other real estate controlled by TATA POWER through ownership, lease, or rental.

Included are walkways (including from the parking area to the facility entrance)‚ lunchrooms‚ cafeterias‚ locker rooms‚ toilets‚ and washrooms‚ as well as banks or other establishments provided within the secured area for TATA POWER employees.

The following are not considered to be TATA POWER premises:

TATA POWER - owned property leased to others

Public areas

Recreational facilities Serious Process Incident (SPI) - a process incident as described above that

scores 130 points or higher using the scoring system described in Annexure E, including incidents that result in a fatality, multiple lost workdays, or that have any of the following actual off-site impacts classified as automatic SPIs: evacuation, non precautionary shelter-in-place, injury, major media coverage, significant damage to property, significant community impact, or overnight hospitalization.

Severity categories - Categories that denote the impact of an injury or illness on health and work.



Sign - an observable or measurable (objective) indication of an injury or illness. Site SHE - Site competency that includes safety, occupational health,

ergonomic, fire and environmental resources. Symptom - A non observable (i.e., subjective) indication (e.g., pain, numbness,

nausea, or shortness of breath) of an injury or illness. Under TATA POWER control— A shipment made by a TATA POWER site or by

those acting as agents of the company, including contracted warehouses, terminals, transloading operations, and contracted manufacturers, whereby the TATA POWER or its agent selects the carrier; and does not include shipments transported by customer-designated or owned carriers not approved by the TATA POWER.

Work-related activity – any activity that is a condition of employment. Included are activities on TATA POWER premises or while on TATA POWER business off TATA POWER premises.

Visitor— A person on TATA POWER premises who is neither a contract employee nor a contractor employee.

Wellness and work conditioning program - a course of actions aimed at promoting employees’ health, well-being, and fitness for duty.

Work-related activity— Any activity that is a condition of employment. Included are activities on TATA POWER premises or while on TATA POWER business off TATA POWER premises.



Annexure – B Incident Investigation Flow Chart



Annexure – C Initial Report (Incident /Injury/ Illness)



Annexure – D Initial Report (Distribution Incident)

INITIAL INCIDENT REPORT - DISTRIBUTION INCIDENT

Location of Incident (Country / State / City / Road / off Road):

Company / Location and Dispatch point:

Date: Time:

Mode of transport:

Product / substance involved:Quantity Released:

Packaging:

Company Involved:

Company Owned Vehicle

Leased Vehicle

Contracted Vehicle

Customer Vehicle

Vendor Vehicle

Transport Contractor Name:

Cause category: (container failure; container securing; handling incident; load, block, and brace; or transportation incident)

Description of Incident:- What happened: {Provide a short summary of incident facts known at present (e.g. Status of personnel or equipment, name of material and approximate quantity involved, and the potential severity of outcomes) including Off-Site / location impacts:

People: No. of injuries No. of fatalities Description / details

Employee

Contractor

Third party

Total Point Value, including score sheet:

Immediate actions taken:

What assistance has been requested:

External Agencies Involved (e.g. Fire brigade, Local Police etc.)

News media coverage:

Reported By: Date / Time Reported:

Annexure – E PFDE Incident scoring guidance



Process, fire, distribution, and environmental incident scoring guidance 1. On basis of ‘ Hazards and materials involved’ Characteristics of the incident - Points Proc

a Fire

Dist.

Envb

Highly toxic chemicals a 20 N/A N/A 20

Flammable liquids b and gases in a building 20 30 N/A N/A

Materials with explosion c potential due to physical/chemical characteristics and/or conditions of use

N/A N/A 15 N/A

Combustible liquids d in a wooden building e 20 20 N/A N/A

Materials c, due to the small quantity released or the lack of confinement, that do not pose significant hazard explosion potential; asphyxiants f combustible liquids handled below their flash points; and materials containing significant stored energy due to high pressure and/or temperature g

10 10 N/A N/A

Materials having significant adverse effect potential h 10 N/A N/A 10

Other process materials i 5 5 N/A 5

Innocuous man-made materials j 0 N/A N/A 0

Innocuous naturally occurring materials k 0 N/A N/A 0

Release of transport-regulated goods, Packing Group I l and Toxic Gases l

N/A N/A 20 N/A

Release of transport-regulated goods, Packing Group II l N/A N/A 15 N/A

Release of transport-regulated goods, Packing Group III l N/A N/A 10 N/A



Release of goods dangerous for supply/use N/A N/A 10 N/A

Release of innocuous man-made material j N/A N/A 5 N/A

Release of innocuous natural material k N/A N/A 0 N/A

a Highly toxic chemicals are listed in Annexure K; other comparable substances may be designated by Sites.

b A flammable liquid is a liquid with a closed-cup flash point below 38°C. If both flammable and combustible liquids are present, select the flammable liquid response.

c These materials may include flammable gases, flammable liquids (particularly if handled above atmospheric pressure and/or boiling point), combustible liquids above their flash point or at pressures sufficient to generate aerosol mists if released, combustible dusts, flammable solids(e.g., sodium metal or aluminum powder), and thermally unstable materials (e.g., sodium, dinitrobenzene). Note: If confined, relatively small amounts of any of these materials may present an explosion hazard.

d A combustible liquid is any liquid that has a closed-cup flash point at or above 38°C. If both flammable and combustible liquids are present, select the flammable liquid response.

e A wooden building is built around a wooden frame or has 50% wooden surface area of the floor, ceiling, and walls.

f Asphyxiants include nitrogen, carbon dioxide, water (i.e., drowning), or other materials, depending on incident circumstances.

g These materials include high-pressure steam (>20 Kg/cm2 ). h These materials are chemical substances (e.g., toxics and corrosives) whose

potential exposure to human, animal, aquatic, or plant life is a concern; however, they do not meet the criteria for a higher point score.

i These materials include low-toxicity or combustible solids. j These materials include non toxic polymers, plastics, and non toxic salts. If they

present no process hazard, there are 0 process points. k These materials include pure water, nitrogen, and carbon dioxide. (For process

incidents, these substances must have presented no process hazard or asphyxiation hazard in this incident.)

l See Packing Group and Toxic Gases in “Recommendations on the Transport of Dangerous Goods Model Regulations,” United Nations, New York and Geneva, or the local country or regional regulations.

2. On basis of ‘ Actual size ‘

Characteristics of the incident Points Proc

a Fire

Dist.

Env.b

Very large c 30 N/A 30 30

Large d 20 20 20 20



Moderate e 10 10 10 10

Small f 5 5 5 5

Very small g highly toxic chemical h 5 N/A 5 5

All other, very small i non-highly toxic chemical h

0 N/A 0 0

N/A = Not applicable

a For a process incident, the whole release quantity should be scored.

Include material that is transferred into the wrong piece(s) of equipment. b For environmental incidents, if some of a release is captured in a properly

engineered containment system, then only the quantity of material that escapes from containment into the environment (i.e., air, water, or soil) should be scored.

c Release >25000 kg. d For process, environment, and distribution incidents, release 500 to 25000

kg). For fires, footprint (area) larger than 7.0 sq meters. e For process, environment, and distribution incidents, release >25 to 500

kg. For fires, footprint (area) more than 1.0 sq meters and lesser than 7.0 m2.

f For process, environment, and distribution incidents, release <25 kg. For fires, footprint (area) lesser than a 1.0 sq mt.

g For process, environment, and distribution incidents, release < 1.0 kg. A “very small release” refers to a drip or an instantaneous release (e.g., a “puff”); for fire incidents, footprint (area) smaller than a trash can.

h Highly toxic chemicals are listed in Annexure K other comparable substances may be designated by Sites.

i For process, environment, and distribution incidents, release <1.0 kg. A “very small release” refers to a drip or an instantaneous release (e.g., a “puff”).

3. On basis of ‘Potential’

Characteristics of the incident

Points

Proc. a

Fire b

Dist.

Env.

Large c 20 20 N/A N/A

Moderate d 10 10 N/A N/A

Small e 5 0 N/A N/A




a For process incidents, the intent is to define the quantity that

could be released under less favorable circumstances. For example: (i) A release in a remote location or one that is not readily detectable could have gone on for the time period associated with the maximum normal patrolling frequency. The longer time should be used when calculating the potential release quantity. (ii) For an incident in a system with readily accessible standard isolation points (valves), this isolation capability may be considered when determining the potential release quantity. (iii) For an incident in a system without standard isolation capability (e.g., a leak between the vessel and an isolation valve), the total system inventory must be used as the potential release quantity, even if the leak was stopped by such measures as banding, plugging, or clamping. (iv) A leak occurred when the storage tank was half full; however, it is normally full.

b For fires, “potential” means the actual size of the flammable liquid pool.

c For process incidents, potential release >10,000 kg; for fires, flammable liquid pool

larger than a pallet approximately 1.5 sq meters. d For process incidents, potential release 2,500 to 10,000 kg; for

fires, flammable liquid pool smaller than a pallet. e For process incidents, potential release <2,500 kg; for fires, no

flammable liquid pool.

4. On basis of ‘ Degree of control a site had during the incident’

Characteristics of the incident

Points

Proc. b

Fire c

Dist.

Env.

Event was not controlled d 20 30 N/A N/A

Event was partially in control e

10 15 N/A N/A

Event was in control f 5 5 N/A N/A


a If an incident occurs, there was some loss of control. The degree of loss of control depends on the degree to which human (e.g., putting out a fire with a fire extinguisher by a standby person pre-positioned for that purpose) or engineering controls after the incident occurred decreased the consequences (i.e., severity



and/or duration) of the incident.

b Score 20 points for (1) catastrophic failure of pipeline/vessel, (2) transfer of material to wrong vessel, or (3) fingers crushed in rotating process equipment that is operating or in use. Score 10 points for (1) released material contained by dike or (2) vapor release from storage tank stopped by venting tank to 0 Kg/cm2 to scrubber. Score 5 points for events where all lines of defense worked as designed. Depending on the circumstances of the incident, score 5 or 10 points for (1) interlock test failure, or (2) pressure relief device test failure, or (3) compromising a line of defense. Significant excursions of process variables (e.g., temperature, pressure, or inhibitor flow), depending on the incident, can range from “in control” (5 points) to “not controlled” (20 points).

c Score 30 points for fires where all fuel is consumed (see 5-point example). Score 15 points for fires involving flammable gases and the fuel supply is manually closed or fires with all other fuels where the incident is controlled by the emergency response team (ERT) or by fixed suppression (e.g., sprinklers, deluge, foam). Score 5 points for fires with flammable gases and the fuel supply was automatically closed or all other fuels where the incident is controlled by a single fire extinguisher or fuel is consumed before there was an opportunity to intervene.

d Releases with no mitigation capability are considered “not controlled.”

e Mitigation may provide partial control. f When a fire is under control, the spread or extension of the fire

has been stopped. 5. On basis of ‘Involvement of last-line-of-defense safety devices’ a


. Fire

Dist.

Env.

Complete failure b, inadequate design, or mis-operation

20 c N/A N/A N/A

Last line of defense compromised even with no release

20 N/A N/A N/A

Partial function but significantly compromised 10 N/A N/A N/A

Partial function but minimally compromised 5 N/A N/A N/A

Functioned as designed or not applicable 0 N/A N/A N/A

N/A = Not applicable Document No.-P-006 Page 31 of 62 Rev. No. R-

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a These devices include relief valves, interlocks, flares, scrubbers,

barricades, dikes, block or isolation valves, excess flow valves, and level devices.

b Complete failure shall include failure or partial function of safety devices during routine checks and interlock bypasses.

c If there is no last line of defense, but a possible line of defense could have reasonably been included in the design, consider a score of 20 points for inadequate design (e.g., a 200 litres drum of material ruptures and leaks in an area without containment dikes) as against “not applicable.”

6. On basis of ‘Actual on-site impact’ a


. Fire

Dist.

Env.

Actual fatality or multiple lost time injuries b(LWCs)

- AUTOMATIC SERIOUS PROCESS INCIDENT (SPI), CATEGORY A FIRE

30 30 N/A N/A

Actual single LWC or incident resulted in disruption c to a plant area outside release area d

20 20 N/A 20

Significant damage to wildlife, vegetation, or property e

N/A N/A N/A 20

One or more actual recordable injuries or incident resulted in disruption f only within area where release originated

10 10 N/A 10

Minimal disruption f to operations 5 5 N/A 5

No disruption g to operations 0 0 N/A 0


a Non-TATA POWER operations that are within the TATA POWER site/facility boundaries (e.g., a contract maintenance shop) should be treated as an on-site impact.

b To anyone. c If in retrospect, the facility determines that evacuation should

have occurred on-site, the higher number of points shall be assigned (e.g., evacuation or emergency process shutdown,



emergency response). d An area is one or more operations under the same control of one

manufacturing organization. e Significant damage to property includes significant soil and/or

groundwater contamination. f Disruption includes evacuation, emergency process shutdown, or

non-precautionary emergency response. g No disruption to operations means no production impact and only

minor non-production impact. 7. On basis of ‘ Potential a on-site impact b of actual incident’ c


. Fire

Dist.

Env.

Potential lost time injury (LWC) or release resulted in potential disruption d to a plant area outside release area e

20 N/A N/A N/A

Potential for one or more recordable injuries 10 N/A N/A N/A

Release resulted in potential disruption d only within area where release originated; potential minimal disruption to operations

5 N/A N/A N/A

No recordable injury potential; no potential disruption d to operations

0 N/A N/A N/A


a Sites should ask the following, and similar, questions: What if weather

conditions had been different? What if the wind had been blowing toward populated areas? What if the release or incident had occurred on a different shift or day?

b Sites shall consider populations that could have been affected by the actual incident or release volume. Non-TATA POWER operations that are within the TATA POWER site/facility boundaries (e.g., a contract maintenance shop) should be treated as an on-site impact.

c If the incident involved an actual LWC or disruption of operations, this item should be scored based on the potential of the incident to have caused additional, or more severe, injuries or impacts.

d Disruption includes evacuation, emergency process shutdown, or emergency response.

e An area is one or more operations under the same control of one manufacturing organization.

8. On basis of ‘Actual off-site impact’ a

Characteristics of the incident Points Document No.-P-006 Page 33 of 62 Rev. No. R-

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Proc.

Fire

Dist.

Env.

Actual evacuation, non precautionary shelter-in-place b, injury, major media coverage c, significant damage to property d, significant community impact e, overnight hospitalization— AUTOMATIC SPI, CATEGORY A, ENVIRONMENTAL, OR FIRE

Environmental only: significant damage to wildlife, aquatic life, or plant life— AUTOMATIC CATEGORY A ENVIRONMENTAL Illness/injury due to release results in overnight hospitalization or causes death—AUTOMATIC CATEGORY A DISTRIBUTION

20 30 20 f 20

Community complaints, immediate national reporting g, permit exceedances, limited off-site impact h, precautionary shelter-in- place

10 20 10 10

Minimal off-site impact i with no precautionary shelter-in-place

5 5 5 5

No off-site impact and no precautionary shelter-in-place 0 0 0 0

a Non-TATA POWER operations that are within the TATA POWER site/facility

boundaries (e.g., a contract maintenance shop) should be treated as an on-site impact.

b If, in retrospect, the facility determines that either evacuation or shelter-in-place should have occurred off-site but did not, the incident shall be scored as an automatic Category A and SPI. If it is determined that hazardous conditions never existed during the incident and shelter-in- place was unnecessary, it may be considered precautionary and is not an automatic Category A incident or an SPI.

c “Major media coverage” includes coverage at the time of the incident by national news media or major coverage by local news media.

d “Off-site damage to property” includes groundwater, surface water, or soil contamination.

e “Significant community impact” could include street closings or contamination of a drinking water supply.

f For distribution incidents, 10 points can be scored for a precautionary evacuation of a transport facility that does not involve evacuation of the general public or any other impacts that would otherwise trigger a 20-point score.

g If immediate national reporting is not warranted, the site may choose not to score 10 points for reporting the incident. For a country with no national reporting requirements, the local, state, or provincial requirements shall be used to trigger the regulatory reporting criteria. In the absence of reporting requirements, sites should report according to the severity of the incident.

h “Limited off-site impact” includes response by outside agencies when they actively participate in mitigating the events and minor, reversible damage to wildlife or vegetation.

i “Minimal off-site impact” means material may have left the site but did not cause any of the impacts scored 10 points or higher (e.g., small air release).

Document No.-P-006 Page 34 of 62 Rev. No. R-

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9. On basis of ’Potential a off-site impact b of actual incident’


. Fire

Dist. Env.

Potential evacuation, shelter-in-place, injury c, major media coverage, significant damage to property, significant community impact, overnight hospitalization

20 N/A N/A N/A

Potential community complaints, potential limited off-site impact, potential precautionary shelter-in-place

10 N/A N/A N/A

Potential minimal off-site impact 5 N/A N/A N/A

No potential off-site impact 0 N/A N/A N/A

N/A = Not applicable a Sites should ask the following, and similar, questions: What if weather conditions

had been different? What if the wind had been blowing toward populated areas? What if the release or incident had occurred on a different shift or day?

b Sites shall consider populations that could have been affected by the actual incident or release volume. Non-TATA POWER operations that are within the TATA POWER site/facility boundaries (e.g., a contract maintenance shop) should be treated as an on-site impact.

c Injuries could also include illnesses and irreversible health effects (i.e., ERPG 2 levels).

10. On basis of –‘Actual monetary loss in property a damage, lost revenue due to

business interruption b, and other costs c associated with the incident’


. Fire

Dist.

Env.

High, Rs. 1.0 — AUTOMATIC SPI, CATEGORY A FIRE

20 20 N/A N/A

Moderate, Rs. 10.0L to < Rs. 1.0 crores 10 10 N/A N/A

Low, Rs. 1.0 L to < Rs. 10.0 L 5 5 N/A N/A

Very low, < Rs. 1.0 L 0 0 N/A N/A


a Property (plant and equipment) loss—This would equal the entire replacement cost of property destroyed, the cost of repair to damaged



property, and associated labor costs. b Business interruption—This would equal the lost profits from any production

downtime plus any extra expenses (e.g., leasing substitute equipment and/or office space) incurred during the same period. In addition, the company could suffer loss of customers/market share to competitors, reduced profits due to higher cost of manufacturer, or purchase of replacement inventory at a penalty.

c Other costs associated with the incident could include, for example, legal fees, fines, penalties, environmental cleanup expenses, and injury costs (e.g., medical treatment, lost time, workers compensation).

Process incident

Fires

Distribution incident

Environmental incident

Total points Type/

category SPI A A A

PI B B B C C



Annexure F – Safety Area Ownership Details



Annexure G—Guidance for determining key factors

Key factors are determined through Root cause analysis.

Root cause analysisPrinciples of “root cause” analysis endorsed by many safety and health professionals are useful in identifying areas for improvement (especially system improvements) that can help prevent recurrence of incidents. These principles are not designed to identify precise cause/effect relationships or to otherwise affix blame. Rather, they are designed to assist investigators in their efforts at identifying those factors that reasonably may have contributed to the occurrence of the event even though a precise, after-the-fact, causal link cannot be determined. The investigators then examine those factors to determine what may have contributed, in turn, to their occurrence. This step-wise approach will ultimately lead to the identification of factors that may be at the “root” of other factors. The site does not support the labeling of the products of investigations as “causes” or “root causes” for the following two reasons: The inherent difficulties in accurately identifying actual cause/effect

relationships in any after-the-fact investigation The significance that may be attached to these terms in civil courts where the

assessment of precise cause/effect relationships and/or the affixing of blame are of paramount concern

The site nonetheless endorses the following “root cause” method of analysis as the preferred approach to maximize the learnings from incidents. It should be used to identify key factors.As defined in the text of this document, key factors are those circumstances that may have contributed to the incident’s occurrence even though a clear causal connection cannot be found. These factors may include human, equipment, or management categories/systems that are found to be deficient or otherwise capable of being improved.Examples of key factors include the following: An operator did not properly follow the operating procedures. The fire water pump bearings failed, causing a shutdown of the fire water

pump during a fire. Pump bearings are not included in the site preventive or predictive maintenance programs.

Operator procedures for non-routine tasks are not included in the current operator training program.

After an incident occurs, an investigation is held as soon as possible to determine all of the key factors.From the list of key factors, a list of recommendations, or follow-up actions, can be generated. When the recommendations are implemented, the possibility of the same incident recurring is reduced.

For each item that occurred, identify what events/situations may have caused or contributed to it (“causes”).

Each of these can then be evaluated to identify what events/situations may have caused or contributed to it, for example by asking “why did this happen?”



For each “answer,” again ask what events/ situations may have caused or contributed to it. At some point the team needs to ask: “What management systems (e.g., training or auditing) were lacking or otherwise capable of being improved?”

Continue looking for the “cause” of each possible factor identified until the endpoint is reached: the most basic “cause” or “root cause”. Often, the endpoint is one of the PSM elements (e.g., training or operating procedures) that needs to be improved. These endpoints are also considered to be “key factors” and should be noted as such in the report.

Another possible endpoint is when a point is reached where the event cannot be controlled internally by the location alone. In these cases, the investigation would involve outside organizations as appropriate. In addition, the investigation would look at how to reduce effects from external sources. (For example, a failure due to a defective part supplied by a vendor is not simply out of the control of the site. Actions [e.g., quality control] can be implemented to prevent this type of incident from occurring.)

After identifying all the key factors, the theories should be tested against the chronology and other pertinent facts. The team may need to modify its conclusions to fit the facts.

Lastly, recommendations are developed based on the key factors identified.



Examples of a “root cause” analysis (Why – why analysis)Example 1 - Incident: Employee slipped on wet spot on floor and sprained his ankle.Questions asked by team:

Response found:

Why was the floor wet?

Leak from pipe.

Why did pipe leak? Corrosion.Why did it corrode? Wrong material of construction.When was wrong material installed?

Original installation.

Why was wrong material installed?

Quality assurance (QA) procedures were not adequate. There is no requirement for inspection by qualified personnel.

The team then recommended modifying the site QA procedure to require inspection and documentation of the inspection of all new/modified equipment to ensure construction matches design specifications. Also, the site PSM audit protocol should be modified to verify that QA requirements are implemented.

Example 2 - Incident: A forklift truck (FLT) began to leak oil. The investigation team found the following:Why did the FLT leak? There was a bad seal.

Seal was just replaced. Why did new seal leak?

Wrong seal was used.

Where did incorrect seal come from? Was ordered by purchasing.

Why did purchasing order the incorrect seal?

Their specification was incorrect.

Why was specification incorrect? Only had one specification for all FLTs and this brand of truck needed a different seal than the others.

The team recommended that additional specifications were needed for the different brand of truck. Additionally when new equipment is brought on site, verification is needed that correct specifications exist for replacement parts. The team also noted that although this was not a process incident, the Process Safety Management elements that applied are Process Technology and Quality Assurance.



Definition of Key Factors:

PHYSICAL FACTORS: Usually becomes apparent through observations – hardware, machines, vessels, etc

HUMAN FACTORS: Acting inappropriately or failing to act ,intentional behavior , mistakes, lack of awareness ,not knowing , etc.

SYSTEM FACTORS: Communications, procedure, training, documentation, policies, standards of performance, etc.

Example 1:

When climbing a scaffold ladder, a contractor employee fell and landed on his left foot, which resulted in a knee injury to his right leg. The medical diagnosis was a multi fragment fracture of the tibia and fibula bones at the knee joint. There was no impact to the operation of the plant, facilities or environment. Surgery was required and full recovery expected

PHYSICAL FACTORS:

The Scaffold fell down: • It was not secured • Ladder position oriented over the scaffold long side • Casters position oriented towards the most instable point • Lack of casters secure pins • Inadequate scaffold dimensions (base vs. height)

HUMAN FACTORS:

a. Scaffold assembling and the use of it without proper training and training materials.

b. Not installing the secure pins for fixing the casters to the scaffold. c.Failure to be concerned when they detected the instability problem.

SYSTEM FACTORS:

•Lack of formal training system for scaffolds assembling/ disassembling •Deficiency on plant procedures ‘PS-123’, ‘PCO-456’ for scaffolds, they do

not included critical elements nor have consistency with the corporate ‘Engineering Standard XYZ1, Scaffolds’ and ‘A.2.1. Scaffolds Safety for Scaffolds Assembling/ Disassembling/ use.’

Example 2:

A. Physical Cause:Machine was in Auto mode.

B. Human Cause:Failure to follow the SOPFollowing short cuts for doing the job. (Overconfidence)

C. System Cause:

Moving parts of the machine are accessible while the m/c is in auto mode.Document No.-P-006 Page 41 of 62 Rev. No. R-

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Example 3:

A. Human Cause:An operator did not properly follow the operating procedures .

C. System Cause:

The fire water pump bearing failed ,causing a shutdown of the fire water pump during a fire . Pump bearings are not included in the site preventive or predictive maintenance programs.

Operator procedure for non-routine tasks are not included in the current operator training program .

Example 4:

Motor Drive failure

A. Physical Cause:Too small a fuse was installed in an application, which resulted in the fuse

blowing apart catastrophically. The explosion took out many other fuses in a domino effect which left many functions inoperable.

B. Human Cause:Did not know proper fuse rating. Fuse rating label not read.

C. System Cause:

Inadequate training, supervision and accountability.




WHY TREE

CI2 RELEASED TO ATMOSPHERE

Scrubber not designed to handle

CI2 Gas Stream

Sent CI2 gas to Finishing instead of raw slurry

CI2 exceeded Scrubber Capacity

Single pump used for both recirculation and sending to Finishing

Slurry recirculation line had open path to

Finishing

No back pressure on Recirculation line

Pluggage in the line of #3 pump

Improper mixing of slurry due to greater

flow to Finishing

Made change in operating practice to increase efficiency of pump (w/o) PCR (to

incr. flow to Finishing)

Single pump used for both recirculation and sending to Finishing


Annexure H—Guidance for determining PSM elements that need strengthening

This guide may be used to aid in determining the Process Safety Management (PSM) Element(s) that need strengthening.

Check this element on the Incident Report

If review of identified key factors indicates that:

Process Technology Improvements could be made in documentation and/or understanding of: Hazards of materials Process design basis Equipment design basis

Process Hazards Analysis Improvements could be made in: Conducting and/or documenting the Process Hazards Analysis (PHA) Depth of the PHA Timeliness of addressing PHA recommendations

Operating Procedures and Safe Work Practices

Improvements could be made in the development, clarity, accessibility and/or approval of: Operating procedures or safe work practices Maintenance procedures

Management of Change—Technology

Improvements could be made in the development, approval, and/or authorization of a COD (Change of Design)/TA (Test Authorization) for the change

Improvements could be made in the documentation of some of these features in the COD/TA: Purpose of the change Technical basis for the change Description of the change Safety, Health, and Environmental impact, including

acknowledgment of whether a PHR is required Analysis of the change Modifications to operating procedures Training/communication to personnel Limits for the change Approval and authorization “Face Sheet” controls: operating procedures, P&IDs, and PHR

Training and Performance Improvements could be made in: Operating or Maintenance personnel training (includes initial or

refresher training requirements) Personnel “fitness for duty” Operating excellence (discipline)

Contractor Safety Contractor personnel were involved in the incident Improvements could be made in how the site manages its PSM

responsibilities for the safety of the contract personnel and/or in how the contractor manages its SM responsibilities for the safety of site personnel.



Annexure H—Guidance for determining PSM elements that needs strengthening (continued)


Check this element on the Incident Report

If review of identified key factors indicates that:

Management of Change—Personnel

Improvements could be made in managing movement of personnel to increase the following: Specific direct process experience Knowledge and skill in managing process safety

Incident Investigation Improvements could be made in: Thoroughness of the investigation of a previous similar incident Timeliness of completion of recommendation(s) from a previous

similar incident Identifying appropriate Key Factors and developing recommendations

from these in a previous incident Sharing Incident Reports with potentially affected personnel

Emergency Planning and Response

Improvements could be made in: Mitigation of impact on personnel, environment, and/or facilities Controlling the emergency situation promptly Emergency plans

Auditing Improvements could be made in the conduct, depth, or follow up of Audit(s)

Quality Assurance Improvements could be made in Developing or following procedures to ensure fabrication, delivery,

assembly, and installation per design specifications Checking received equipment or materials

Mechanical Integrity An unexpected failure of a mechanical or instrument system occurred (e.g., piping, equipment, relief device, or interlock failure)

Improvements could be made in: Conduct, timeliness, or documentation of equipment inspections and

tests, including predictive and preventive maintenance Involving technical resources to assist in assessing the

reliability/integrity of equipment

Pre-startup safety reviews Improvements could be made in: Conduct, depth and/or documentation of Pre-Startup Safety Review

(PSSR) Timeliness of completing recommendations from the PSSR (either

prior to startup or soon thereafter)

Management of Change—Technology

Improvements could be made in: Completion of COD/design package Developing, approving and/or authorizing according to procedure of a

“Subtle Change” COD


Annexure –I Model Investigation Report

CLASSIFICATION: Tick or enter information appropriately Injuries Illness FAC MTC RWC LWC √ FATALITY Numbers 1 Who? Employee Contractor √ Third party Environmental Rating

A B C Points 0

Process Rating SPC Others Points 0 Fire A B C Points 0 Distribution A B C Points 0 OTJ Personal Security

Incident Title: “An Employee Injury When Falling From a Scaffold Ladder”

Location: Company A Incident No.:

LWC-05-0001

Incident Date: October 3, 2005

PHA Record:

Time: 11:15 am Issuing Date:

October 11 2005

Investigation Initiated on:

October 4 2005

SUMMARY When climbing a scaffold ladder, a contractor employee fell and landed on his left foot, which resulted in a knee injury to his right leg. The medical diagnosis was a multi fragment fracture of the tibia and fibula bones at the knee joint. There was no impact to the operation of the plant, facilities or environment. Surgery was required and full recovery expected.

DESCRIPTION On October 3rd 2005 two electrical employees from a Contractor company were performing jobs related to modifying the height of fixtures in a warehouse location. In order to perform this job they were using a rolling scaffold, “Basic Industries” brand armed with wheels and an integrated ladder. The employee was climbing the scaffold ladder and when at a height of approximately 1.5 Mt. from the floor the employee felt that the scaffold was tipping towards him and he jumped to avoid being hit, managing to stay out from under the scaffold. When landing his right leg supported all of his body weight. The scaffold ended up overturned on the floor. Another worker was observing from a distance of approximately 3 Mt. After he realised that his coworker was injured he went for help.

The employee received medical assistance at the contractor’s medical location and after this, was sent to a local hospital for medical attention, where he was diagnosed with



multi fragment fracture of the tibia and fibula bones, at the knee joint.

All contractor jobs were stopped, to inform the employees of the event, requesting to carefully review the involved risks in every activity to take the appropriate precautions.

INVESTIGATION FINDINGS: 1) Work using this scaffold started 10 days prior to the incident on September 23rd

2005. The jobs consisted of: bracket installation, conduit piping, and raise the lamps heights. The portable scaffold was erected on that day for its use.

2) One day before starting the job, (September 22nd 2005) a safety planning was performed to evaluate the job risks. This planning was reviewed and approved by the Contractor Supervisor, Contractor Safety Supervisor, Plant Supervisor and the location responsible, in accordance with the company’s documented Safety Procedure. This safety planning was considered the use as a tool and the scaffold design was not part of the planning. This safety planning was considering the usage of the harness with fall arrestor for the person working on the scaffold.

3) The scaffold components were from “basic industries” and have dimensions of 0.90 x 1.50 x 3.75 meters (to the top of the scaffold) and 2.80 meters (to the top of the platform). A ladder of the same brand was installed, supported from one of the 4 vertical poles of the scaffold. Also casters were installed to facilitate moving from location to location, over the concrete floor. Personnel who armed the scaffold did not detect instability risks. They determined the scaffold dimensions (long/wide) based on workspace needed.

4) Personnel, installing the brackets and conduit pipe started to use the scaffold on September 23rd 2005 and finished with this activity on September 28th 2005. These employees did not report instability problems with the scaffold.

5) On September 29th 2005, the jobs to modify the lamp height were initiated. The modification consisted of shortening by 20cm to the support pipe of each of the 16 lamps. This job was being performed by other groups of electrical employees. To reach the lamps hanging from the roof an employee climbed the scaffold ladder up to the scaffold platform.

6) Up to the time of the incident, 8 to 16 lamps had already been modified. To perform each modification the employee climbs to the platform tow or more times.

7) The scaffold was not ‘tied’ off to ensure its stability. 8) During the investigation, an employee commented that he observed in some

occasions that the wheels opposite site / location the ladder were moving when one of his coworkers was climbing the ladder but were stable after accessing the top of the platform. He did not relate this with a stability problem.

9) The injured employee was using a safety harness with fall arrestor according the performed safety planning. However, in agreement with the documented Working at Heights Procedure, the usage of a fall arrestor is required to climb and descend ladders over 3 meters in height. However, in addition because the scaffold was tied off it was not advisable to use the fall arrestor because the force of a fall could overturn the scaffold.

10) The scaffold ladder was attached on the long side and the gap between the ladders to the scaffold edge is approximately 8 inches. With these conditions, the scaffold became unstable due to the dimensions used in construction.

11) The type of casters used on this scaffold has a distance of 3 inches between the axis of the support centre of the wheel and the connection point to the scaffold pole, (Refer Figure 1). With the fallen scaffold it was found that this misalignment was favorable to lose the centre of gravity of the scaffold.

12) The electricians using the scaffold positioned the scaffold under the lamps they



were working on and once it was placed they engaged the brakes without considering the orientation of the wheels in regard to the stability of the scaffold.

13) A welder that previously used this same scaffold commented that he didn’t feel that the scaffold had moved and that he pointed the wheels facing ‘outside’ because he was aware of this condition due to other experiences.

14) The two casters that remained connected to the fallen scaffold indicate that their position was to the inside. That is unfavorable in regard to the scaffold stability.

15) The holding pins were not installed in the scaffold wheels. When the scaffold fell, the wheels opposite to the fall fell out, (Refer Figure 2).

16) The employee who erected the scaffold claims that the holding pins were in fact installed in each caster of the scaffold. The employees using the scaffold were not aware if they were installed or not. It is very unlikely that the four of them had loosened because of the scaffold movement; therefore the investigation team concluded that they were actually not installed.

17) Each wheel has a weight of 21.4 kg and if they lack holding pins this contributed to the scaffold instability, since the weight of the employee was not compensated. (Refer Figures 5 & 6).

18) During this investigation, a stability test was performed to the same scaffold in the field, with the scaffold secured, confirming that because the wheels did not have the holding pins in place, when using the ladder to go up and deliberately unbalance the scaffold; the wheels opposite to the ladder separated from the vertical pole.

19) Only a special crew from a contractor company performs the process of assembling and disassembling the scaffold in the plant.

20) The scaffold crew Supervisor was trained in the assembly of ‘basic industries’ scaffolds in 1996 by the scaffold supplier. He has been in this assignment since this date. No further training has been received.

21) The employees from the scaffold crew have never received formal training. They have developed their skills and knowledge through the years under the Supervisors guidance.

22) The company’s Standard XYZ1 for working on Scaffolds establishes that all scaffold work should be performed under the direction of “competent person”…..”The scaffolds should be assembled, dismantled moved and modified only under the guidance of a competent person and by employees who have received an appropriate and specific training for the work they perform.”

23) According to Standard XYZ1 the definition of “competent person” is the one that has through years of experience has as follows:

24) Knowledge of the regulations applicable to scaffolds. 25) Is capable to identify existing and predictable risks related to the erection,

alterations, dismantling, storage and inspection of scaffolds. 26) Has the authority to take a quick corrective action to eliminate such risks. 27) The Standard XYZ1 also indicates a requirement to “secure” the scaffold when its

height exceeds four times the narrowest side of the scaffold base. This requirement is consistent with the OSHA requirement.

28) The documented ‘Scaffolds Procedure’ from the ‘Construction FCMS Manual’ is consistent with the Standard XYZ1 on the requirement of personnel, that they should be a “competent” person.

29) The ‘Scaffolds Procedure’ also requires securing the scaffolds when its height exceeds 3 times the narrowest dimensions of its base. This requirement is different to the one established in the.

30) At the plant two scaffold procedures exist: ‘No. PS-123 Scaffolds Use’ from the ‘Safety Procedures Manual’ and ‘PCO-456 Scaffolds Assemble/ Disassemble’ from the ‘Construction Job Procedures Manual’.

31) ‘PS-123 Scaffolds Procedure’ describes the safety consideration when using the scaffolds. When reviewing this procedure regarding the incident we found the following:



i) In the “safety/ Quality” Section it states “……For scaffolds assembling/ disassembling, basic trained, properly documented personnel is required….” However, it does not describe any definition or scope of “training or documentation”.

ii) In Point 4 of the ‘Responsibilities Section” it also establishes: “It is the responsibility of the Supervisor assigning the personnel for scaffold assembling/disassembling, the mentioned personnel was trained for that job as well as maintaining the training records.”

iii) It does not indicate definition/ criteria of “capable personnel” for scaffold assembling/disassembling.

iv) It establishes as a requirement the use of tie-offs fastened to solid structures using polypropylene cables for scaffolds 3 meters or more in height to the working platform.

v) It does not indicate the adequate position for installing the access ladder for scaffolds with wheels.

vi) It does not indicate any consideration about the wheel position once the scaffold is positioned regarding its stability.

32) ‘Plant Construction Procedure PCO-456’ establishes that “only properly trained and qualified personnel must perform the scaffolds assembling and disassembling duties.” Therefore it does not establish the criteria for “personnel properly trained and qualified.”

33) This procedure (PCO-456) also establishes that a checklist, verification, tags system indicating the scaffold final assembly condition and if it is safe for using it. This system consists of three different tags including a general checklist verification of each one.

TAGS INDICATION

1 The Scaffold Cannot Be Used

2 The Scaffold Can be Used with Caution (Explain the scaffold Condition in the Tag)

3 The Scaffold is Complete and Can be Used

34) A tag indicating that it did not have a complete handrail, but not limiting its use

identified the scaffold that fell. The same tag indicated in the verification checklist that the tie-off was okay. However, it was confirmed with the personnel who assembled it that it was not tied off when they left it for work.

35) Every year, the ‘Scaffolds Procedure PCO-456’ is communicated and documented to the scaffolds assembling personnel. Last time it was communicated was on May 10th 2002. At the location/ site, this communication process is not considered as formal training.

36) In the ‘Annual Weekly Safety Talks Program’ theme ‘PS-123 Scaffolds’ is considered to be communicated to the contractor personnel at least once a year. This is also not considered formal training.

37) The investigation team considered two contributing factors for this event: 1) Contractor Personnel “confidence excess” on low risk routine jobs. 2) Lack of warning sense for identifying and correcting risks.

Conclusions of the investigation team based on the RCFA (attached) are, PHYSICAL FACTORS: The Scaffold fell down:

• It was not secured • Ladder position oriented over the scaffold long side



• Casters position oriented towards the most instable point • Lack of casters secure pins • Inadequate scaffold dimensions (base vs. height)

HUMAN FACTORS: a. Scaffold assembling and the use of it without proper training and training

materials. b. Not installing the secure pins for fixing the casters to the scaffold. c. Failure to be concerned when they detected the instability problem.

SYSTEM FACTORS: • Lack of formal training system for scaffolds assembling/ disassembling • Deficiency on plant procedures ‘PS-123’, ‘PCO-456’ for scaffolds, they do

not included critical elements nor have consistency with the corporate ‘Engineering Standard XYZ1, Scaffolds’ and ‘A.2.1. Scaffolds Safety for Scaffolds Assembling/ Disassembling/ use.’

RECOMMENDATIONS

Sr No

Description Responsibility

Target date

1. Perform an audit to all scaffolds installed at the plant and correct deficiencies.

Contractor Leader A

Done

2. Establish minimum requirements for scaffolds assembling/ disassembling including the preliminary findings of the investigation, to be immediately used. It includes the requirement of the responsibility definition for certifying the scaffold safety.

Contractor Leader A

Done

3. Reinforce the scaffolds personnel through a documented safety talk, the importance always installing anchor belts or fasten the wheels when assembling scaffolds, as well as understanding the ‘Operative Discipline Concept’.

Contractor B 15.10.05

4. Provide formal training on scaffolds assembling, disassembling, storage, inspection and movement, according to the Standard Requirements to the scaffolds team personnel

Contractor Leader A

30.10.05

5. Provide specific training on ‘Safety Rules for Scaffold Use’ to the contractor personnel using scaffolds.


6. Provide formal training on scaffolds use to all requiring personnel (scaffold users)


7.

Review and modify ‘PS-212 Scaffolds’ for including the following requirements in addition to the ‘SXYZ1 Scaffolds Standard’ and procedure ‘B.2.1.Scaffolds

Contractor C 30.11.0



Safety’ • Every time a mobile scaffold is used, wheels must be oriented to the exterior of the base wide side. • Indicate minimum dimensions required for mobile scaffold height according to the ‘A.2.1. Procedure’. Determine the height base on consulting with other locations and experts. • Establish definitions suitable for the site / location of competent personnel for scaffold assembling/disassembling. • Establish the formal training requirement, certification and records for the use of scaffolds by assembling/ disassembling personnel. • Establish the training requirement for scaffold users. • Establish the frequency training criteria for scaffold assemblers and users. • When a scaffold is identified with a yellow tag, a delivery from the scaffold assembly supervisor to the user supervisor must be carried out. Clarify the full expectations for use of scaffold tags and establish the requirements for periodic re-verification of the safety of scaffolds that are in use. • The end user must not modify the scaffold once it installed. It is required to review the modifications with the scaffold supervisor and he must approve them.

5

8. • Review and modify ‘PCO-456 Scaffolds Assemble/ Disassemble’ to include the following requirements: • Every time a mobile rectangular scaffold is assembled, the ladder must be installed on the narrow side of the base. • Indicate the minimum dimensions required for mobile scaffold height according to ‘A.2.1 Procedure’ that it has to be vented when height exceeds three times the base on the narrow side. • Establish definitions of competent personnel suitable for scaffolds assembling/ disassembling. • Establish the formal training requirement, certification and records for scaffold assembling/ disassembling personnel. • When a scaffold is identified with a yellow tag, a delivery form the scaffold assembly supervisor to the user supervisor must be carried out. • Establish the frequency training criteria for scaffold assemblers/ users. • Include a detailed checklist for the scaffold assembling verification. The checklist must include the scaffold stability evaluation. • Indicate the responsibilities for the scaffold safety verification. • Safety talks do not replace the scaffolds assemblers / users’ formal training.

Contractor A 30.11.05



Approximate cost of the Incident: _____________ APPROVED BY: ________________________________ COMMITTEE: Contractor Leader A (Committee Co-Ordinator) Contractor B Contractor F Contractor C Contractor G Contractor D Contractor HContractor E Contractor I

COMMITTEE COORDINATOR: ____________________________________________________________



Figure 1 Figure 2

Figure 3 “Scaffold Erected”



Figure 4 Fallen Scaffold

Annexure – J Incident Investigation Report Format



FINAL INCIDENT INVESTIGATION REPORT TEMPLATECLASSIFICATION: Tick or enter information appropriately Injuries Illness FAC MT

C RWC

LWC

FATALITY

Numbers Who ? Employee Contract

or Third party

Environmental Rating A B C Points

Process Rating SPC Others Points Fire A B C Points Distribution A B C Points OTJ Personal Security

Incident Title: AN EMPLOYEE INJURY WHILE DRAINING THE HOT CARBONATE SOLUTION

Location: Incident No.:

Incident Date: PHA Record:

Time: Issuing Date:

Investigation Initiated on:

SUMMARY ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

DESCRIPTION ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

INVESTIGATION FINDINGS _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________________________________________________________________________________________________________________



_________________________________________________________________

Conclusions of the investigation team based on the RCFA (attached) are,

1. PHYSICAL FACTORS: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. HUMAN FACTORS:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

3. SYSTEM FACTORS:

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

RECOMMENDATIONS

Sr No.

Description

Responsibility

Target date

1.

2.

3.

4.

5.

PSM ELEMENTS THAT NEED TO BE REINFORCED Document No.-P-006 Page 62 of 62 Rev. No. R-

000


S.N

System Deficiency

Personnel: 1 Training & Development 2 Personnel Changes Management 3 Incident

Investigation/Communication

4 Audit 5 Planning & Emergency Response 6 Contractors Safety &

Development

Facilities: 1 Quality Assurance 2 Mechanical Integrity 3 Pre-Start Up Safety Inspection 4 Subtle Changes Management Technology 1 Process Technology 2 Process Hazard Analysis 3 Operation Procedure & Safety

Practice

8 Change Management-Technology Operative Discipline: 1 Example Leadership 2 Sufficient & Capable Resources 3 Employee Involvement 4 Communication Active Lines 5 Strong Team Work 6 Shared Common values 7 Up-dated Documentation 8 Consistent practices Vs

procedures

9 Shortcut Absence 10 Excellent working location 11 Pride in Organization

Approximate cost of the Incident: _____________ APPROVED BY: ________________________________ COMMITTEE: Contractor Leader A (Committee Coordinator)

Contractor F Contractor B Contractor G Contractor C Contractor H Contractor D Contractor I Contractor E Contractor J

COMMITTEE COORDINATOR:

_____________________________________________



PSM ELEMENTS THAT NEED TO BE REINFORCED

S.N

Development System Vs System Deficiency

Personnel: 1 Training & Development 2 Personnel Changes Management 3 Incident

Investigation/Communication

4 Audit 5 Planning & Emergency Response 6 Contractors Safety &

Development

Facilities: 1 Quality Assurance 2 Mechanical Integrity 3 Pre-Start Up Safety Inspection 4 Subtle Changes Management Technology 1 Process Technology 2 Process Hazard Analysis 3 Operation Procedure & Safety

Practice

8 Change Management-Technology Operative Discipline: 1 Example Leadership 2 Sufficient & Capable Resources 3 Employee Involvement 4 Communication Active Lines 5 Strong Team Work 6 Shared Common values 7 Up-dated Documentation 8 Constant practices Vs procedures 9 Shortcut Absence 10 Excellent working location 11 Pride in Organization

Approximate cost of the Incident: _____________

APPROVED BY: ________________________________ COMMITTEE: _________________________________________________________________________________________________________________________________________________________________________________________________________________________________

COMMITTEE COORDINATOR: ________________________________________________



Annexure – K List of Toxic and hazardous Chemicals used at site

Material CAS No. Vapor Pressure

20-26 deg C(mm Hg)

ERPG-3, ppm

Substance Hazard Index (SHI)

Anhydrous Ammonia 7664-41-7 6420 750 11260Bromine 7726-95-6 170 5 44740Butyl Isocyanate 111-36-4 17 1 22370Carbon monoxide(anhydrous liquid)

630-08-0 >760 500 2000

Chlorine 7782-60-6 5098 20 335400Chlorosulfonic acid 7790-94-5 1.09 6.3 228Dimethylamine 124-40-3 1520 350 57142Ethyl chloroformate 541-41-3 57 10 7500Formaldehyde (anhydrous) 67-56-1 >760 25 40000Fluorine 7782-41-4 >760 20 50000Fluoro sulfonic acid 7789-21-1 2.5 6.1 539Hexa fluoro propylene 116-15-4 4932 500 12978Hydrochloric acid (anhydrous) 7647-01-0 31527 150 27660Hydrogen cyanide 74-90-8 613 25 32260Hydrogen fluoride (anhydrous) 7664-39-3 770 50 20260Hydrogen sulfide (anhydrous) 7783-06-4 13643 100 179500Methyl chloroformate 79-22-1 129 5 33950Methyl isocyanate 624-83-9 337 1.55 295614Methyl mercaptan 74-93-1 1277 100 16380Monomethyl amine 74-89-5 2200 500 5789Nitrogendioxide (anhydrous liquid)

10102-44-0 721 20 47440

Ozone 10028-15-6 >760 2 500000Perfluoro isobutylene 382-21-8 1500 0.3 6579000Phosgene 75-44-5 1195 1 1572000Phosphorous oxychloride 10025-87-3 29 0.85 44890Phosphorous trichloride 7719-12-2 96 5.6 25560Sulfur dioxide (anhydrous liquid)

7446-09-5 2521 15 73710

Sulfurtrioxide / oleum (anhydrous liquid)

7446-11-9 193 9.2 27600

Sulfuryl chloride 7791-25-5 140 7 26320Thionyl chloride 7719-09-7 97 10 12763Titanium tetrachloride 7550-45-0 10 12.9 1020Trimethylamine 121-44-8 1534 500 4260


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