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08_GS_1202_00February 17, 2015

USGC Gulfstream Program of 22The Dow Chemical Company

INCIDENT REPORTING, INVESTIGATION,

REPORT REQUIREMENTS

Incident Reporting, Investigation, This is a controlled document. No un-authorized modifications.Report Requirements Health, Safety, and Environmental

DOW CONFIDENTIAL – Do not share without permission

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Table of Contents

PURPOSE......................................................................................................................................................................4SCOPE...........................................................................................................................................................................4APPLICATION.............................................................................................................................................................4DOW DEFINITIONS...................................................................................................................................................51.0 RESPONSIBILITIES......................................................................................................................................102.0 GENERAL REQUIREMENTS......................................................................................................................103.0 PROJECT HSE................................................................................................................................................104.0 SUPERVISOR/MANAGER............................................................................................................................115.0 CONTRACTORS.............................................................................................................................................116.0 INCIDENT REPORTING..............................................................................................................................127.0 INCIDENT DOCUMENTATION..................................................................................................................148.0 INCIDENT INVESTIGATION........................................................................................................................19.0 OWNER INVESTIGATION ATTENDEES...................................................................................................210.0 CLASSIFYING AND RECORDING INCIDENTS........................................................................................311.0 OTHER REPORTING REQUIREMENTS....................................................................................................4

Overview – Weekly Reports.......................................................................................................................4Overview – Monthly Reports.....................................................................................................................4Overview – Additional Reports.................................................................................................................5Overview – Reporting Procedure..............................................................................................................6

12.0 REFERENCES...................................................................................................................................................7



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Contractor and Client Approvals

Rev Date Pages Description By Checked Approved Client

00 11/1/2013 Document Procedure in final for initial implementation BF

Rev. Date Revision Summary

00 Nov 1, 2013 Initial format for implementation.

Approver Name / Title Signature Date



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PURPOSEThis practice defines the requirements for reporting, investigating, and managing incidents that have health, safety, or environmental significance. The requirements include reporting, investigating, and managing the following:

Occupational injuries and illnesses (including classifying cases for recordkeeping/reporting purposes)

Occupational exposure to toxic substances Motor vehicle incidents Property damage incidents Environmental incidents Near-miss and other health- and safety-related incidents

SCOPEThis practice includes the following major sections:

Responsibilities General Requirements Reporting Investigation Classifying and Recording Incidents Press Releases

APPLICATIONThis practice applies to all work activities and personnel working on the Gulfstream construction sites.

Note: All recording determinations, for recordkeeping purposes, will be made as defined and prescribed by the United States (U.S.) Occupational Safety and Health Administration (OSHA) Recordkeeping Handbook.



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DOW DEFINITIONSThe Total Recordable Incident Rate (TRIR) is calculated as follows:

Total Recordable Incident Rate (TRIR)

Number of Recordable Injuries and Illness x 200,000 Hrs = TRIRTotal Number Hours Worked



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Incident Type Definition

Incident An unintentional and unplanned event causing, or with the potential to cause, injury, illness, property or asset damage, environmental damage, or loss of production. This covers terms such as near miss, near hit, non-injury incident, and similar phrases.

Injury / Illness An injury or illness is an abnormal condition or disorder. Injuries include cases such as, but not limited to, a cut, an insect or animal bite/sting, fracture, sprain, or amputation. Illnesses include both acute and chronic illnesses, such as, but not limited to, a skin disease, respiratory disorder, or poisoning.

Near Miss An unintentional and unplanned incident with the potential to cause injury, illness, property or asset damage, environmental damage, or loss of production.



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First Aid For the purposes of this standard, First Aid includes ONLY: Using a non-prescription medication at nonprescription strength (for medications

available in both prescription and non-prescription form, a recommendation by a physician or other licensed health care professional to use a non-prescription medication at prescription strength is considered medical treatment);

Administering tetanus or tetanus/diptheria immunizations (other immunizations, such as Hepatitis B vaccine or rabies vaccine, are considered medical treatment);

Cleaning, flushing or soaking wounds on the surface of the skin; Using wound coverings such as bandages, Band-Aids™, gauze pads, etc.; or

using butterfly bandages or Steri-Strips™ (wound closing devices such as sutures, staples, medical adhesives, etc., are considered medical treatment);

Using hot or cold therapy; Using any non-rigid means of support, such as elastic bandages, wraps, non-

rigid back belts, etc. (Note: Using devices designed to immobilize parts of the body are considered medical treatment);

Using temporary immobilization devices during transport (e.g., splints, slings, neck collars, back boards, etc.).

Drilling of a fingernail or toenail to relieve pressure, or draining fluid from a blister;

Using eye patches; Removing foreign bodies from the eye using only irrigation or a cotton swab; Removing splinters or foreign material from areas other than the eye by

irrigation, tweezers, cotton swabs or other simple means (Example: magnet, needle, pins and small tools);

Using finger guards; Using massages. Using stretching, strengthening and exercise. (physical

therapy / physiotherapy or chiropractic treatment to treat a specific injury are considered medical treatment);

Drinking fluids for relief of heat stress; Administering an IV as a precautionary procedure prior to diagnosis or during

transport in case medication is needed (To keep open a pathway to facilitate potential treatment).

Administering oxygen as a precautionary procedure provided that the person is not showing symptoms of an injury or illness as determined by Medical Personnel.

NOTE: A visit to a medical facility that does not result in treatment but where any pain, bruising, swelling, discoloration or physical signs from the event or exposure are observed would result in at least a First Aid classification.

LIFE Event An actual life changing injury or fatality event.



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pLIFE Event A potential LIFE incident is any incident which could have resulted in a LIFE Incident had circumstances been slightly different. This includes reportable injuries less severe than a LIFE Incident and non-injury near misses. • A Reportable Injury (Precautionary, FAC, RMTC, RWC or DAWC)

that reasonably that could have escalated to a LIFE type injury. • An unplanned event that did not cause a reportable injury, but

reasonably could have caused a LIFE type injury. • Non-injury pLIFEs associated with Life Critical Standard

(LCS) errors (see section on LIFE and pLIFE Events)• Other non-injury pLIFEs (i.e. no LCS error involved)

Precautionary Medical Visit

A visit to a medical facility that is initiated to ensure that no injury or illness has resulted from a work related event or exposure, with no physical impact detected.Any bruising, swelling, discoloration or physical signs from the event or exposure would result in at least a First Aid classification.

Recordable Medical Treatment Case (RMTC)

A Recordable Medical Treatment Case (RMTC) is a recordable case where: medical treatment is given, or; it is a significant injury or illness, or; Other special cases as defined in requirement 02.11, and; it is not a fatality or a Restricted Work Case (RWC) or a Day Away

from Work Case (DAWC).

Restricted Work Case (RWC)

A Restricted Work Case (RWC) is a recordable case where, because of a work related injury or illness, Facility/Work Group Leadership and/or Medical Personnel, decide with input from the injured/ill person to restrict work activity beyond the day of injury or onset of illness such that:

He/she was kept from performing one or more of his/her routine functions, or He/she was kept from working the full workday that he/she would have

otherwise been scheduled to work, or Medical Personnel recommends that he/she not perform one or more of his/her

routine functions.

Day Away From Work Case (DAWC, LTI)

A Day Away from Work Case (DAWC), also known as a Lost Time Injury (LTI), is a recordable case where, because of a work related injury or illness, Construction site leadership and/or Medical Personnel determine with input from the injured/ill person that he/she is not able to work beyond the day of injury or onset of illness.



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Recordable Case / Recordable / Recorded / Recordability

Those work related deaths, injuries and illnesses that are reported, are submitted into the Global Incident Reporting Database (GIRD) and are included in the performance metrics. Recordable cases include: Fatalities, regardless of the time between the injury, or the length of

illness, and death (all fatalities are classified as DAWCs) Day Away from Work Cases Restricted Work Cases Recordable Medical Treatment Cases Significant Injuries & Illnesses First Aid Cases Precautionary Medical Visits

Reportable Case / Reportable / Reported / Reportability

Those work related deaths, injuries and illnesses and potential injuries and illnesses that must be communicated to the Injury & Illness Incident Classifier for evaluation to determine recordability. Reportable cases include:

Fatalities, regardless of the time between the injury, or the length of illness, and death (all fatalities are classified as DAWCs)

Day Away from Work Cases Restricted Work Cases Recordable Medical Treatment Cases Significant Injuries & Illnesses Other special cases as defined in requirement 02.11 First Aid Cases Precautionary Medical Visits



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1.0 RESPONSIBILITIESTitle: Incident Investigation Report (See separate document) Purpose: Document incidents in detailResponsibility: Supervisor/Manager or designeeDue: Initial by 10:00 AM the next working day. Final report within

5 business days of incidentDistribution: Site Manager/Project Manager, Project/Site HSE Representative, Dow

HSE, Dow Construction Manager

Title: Recordkeeping Classification ProcessPurpose: Injury classification for recordkeeping/reportingResponsibility: Site HSEDue: Within 2 calendar daysDistribution: Site Manager/Project Manager, Project/Site HSE Representative, Dow

HSE, Dow Construction Manager

Title: Project Incident LogPurpose: List of all incidentsResponsibility: Project HSEDue: MonthlyDistribution: Site Manager/Project Manager, Site HSE, Dow HSE, Dow

Construction Manager

Incident investigations should be conducted by an investigative “team” led by a line supervisor or manager at the project level.

2.0 GENERAL REQUIREMENTSThe Dow incident reporting form (Excel document) will be used. See naming convention below.

All persons are responsible for reporting incidents as soon as practicable after becoming aware of the incident occurring

All incidents will be formally reported within the terms and requirements of the relevant in-country, statutory authority.

Incidents should be a topic of a Toolbox Meeting for all affected or potentially affected employees on the project/site/office.

All incidents will be communicated at the weekly all hands meetings.

3.0 Project HSEProject HSE will perform the following:

Assist line management during the investigation.

Review the completed Incident Investigation Report for completeness and accuracy.



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Determine the classification and maintain logs and summaries of the incidents.

Document and report incidents determined to be site-related as required.

Maintain a repository of case file documentation on all occupational injuries/illnesses, vehicle accidents, property loss, and near-miss incidents.

Post copies of the (previous year’s) annual accident summary (OSHA 300A or equal) on bulletin boards by February 1 to permit employees to see the summary on their way to and from work.

Complete an analysis and trend assessment of all incidents and report to construction site management at least monthly.

4.0 SUPERVISOR/MANAGERThe immediate supervisor/manager will follow contractor company requirements. At a minimum, the supervisor will be involved in the investigation.

5.0 CONTRACTORSContractors will submit all incident reports and associated documents to the Gulfstream functional mailbox, [email protected].

Incident reports are to be titled in the following format: Gulfstream Gulfstream_Project_CompanyName_Incident type_MMDDYY

Example: Gulfstream _PDH_Fluor_FirstAid_120214

If more than one incident occurs during a day, add a number to the end of each incident.

Example: Gulfstream _PDH_Fluor_FirstAid_120214_1; Example: Gulfstream _PDH_Fluor_FirstAid_120214_2, etc.



mailto:[email protected]

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6.0 LIFE AND pLIFE INCIDENTSTwo additional categories of events are to be reported to Dow. They are defined as LIFE and pLife events.

LIFE events are events that are actual life altering injuries reported as recordables.

pLIFE events are first aid, precautionary events, or near misses that have the potential to result in a life altering injury if circumstances had been different.

It is important that pLIFE events be investigated as if a severe injury had occurred in order to gather learnings and implement action items to prevent re-occurrence of the event.

Non-injury events related to errors in following the Dow Life Critical Standards (Hot Work, Confined Space Entry, Elevated Work, Electrical Standard, Line and Equipment Opening, Isolation of Energy, Hydroblasting/Pressure Washing) must be investigated and reported as a pLIFE event. Examples include:

High Energy Hot Work in a in a flammable area without a Hot Work Permit

Entry into a Confined Space without a Confined Space Entry permit

Introduction of a hazardous energy source i.e. nitrogen into a confined space while work is in progress

Failure to recognize the requirement for a Life Critical Guard

Aerial lift work or crane work near overhead electrical lines without the proper permits

Excavation without a permit

Other examples of non-injury pLIFE events that are not related to a life critical standard are:

Equipment or material falling into an area where people are working where the equipment or material is of sufficient size to have caused a severe injury

Actual falls from a height of 6 feet or greater where no injury occurs

Any time fall arrest equipment is engaged from a height of 6 feet or more where no injury occurs

Motorized vehicle or equipment contact with a person causing no injury

Exposure to a chemical that could reasonably be anticipated to result in life threatening acute toxicity

Consult with the Dow project safety representative for classification of LIFE and pLIFE events.



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7.0 INCIDENT REPORTINGIncident communication occurs as follows.

Who Does The Contacting Who Do They Contact When Action

Employee involved in incident or co-workers witnessing incident

Foreman/Crew Leader/Supervision

Immediately Report incident Dow – property –

Call for ambulance (site emergency numbers; via radio channel)

Non-Dow property – follow agreed upon process

Foreman/Crew Leader On-site Company Supervision

HSE Representative

Immediately Report Incident

On-site Company Supervision

Contractor company Dow contact

Immediately Report Incident Communicate

Contractor HSE Manager Contacts Gulfstream EH&S Leader or designee

Immediately Report Incident Communicate



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The reporting timeline is as follows.



Immediately after Incident

Complete immediate response activities (ambulance, etc.)Make notifications to DowCollect paperwork (permit, JSA, STAC, PTACC, etc.)Collect witness statementsDevelop timelineTake picturesConduct preliminary investigation

By 10:00 AM Next Working

DayPreliminary report completedCopies sent to Dow Construction Manager, Dow Construction Safety Leader, and Dow Gulfstream EH&S Leader via [email protected]

Before the end of 4 Working

Days Conduct Root Cause Investigation including participants listed below

By Working Day 5 After

Incident Final Report completedCopy sent to FFRGHSE

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8.0 INCIDENT DOCUMENTATIONA copy of the following documentation is required in every incident package if applicable. Dow has the option to request an RCI of a near miss after reviewing the event.

Check Recordable/LIFE/pLIFE

First Aid Precautionary Documentation

X X X Dow Incident Form (Excel document)

X Safe Work Permit & other permits

X STAC

X X PTACC (if applicable)

X JSA

X Training Badge

X Timeline of event

X Photographs (get permission from Dow first)

X X X Employee statements

X Witness statements

X X At Risk status and documentation (if applicable)

X Copy of driver’s license (if MVA)

X Diagram of incident scene if photos can’t be taken

X Photos of involved equipment or tools

X Copy of root cause diagram

X X X Copy of corrective actions or flash report



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Consider the following questions:

WHO• Who was injured?• Who saw the incident?• Who was working with him/her?• Who had instructed/assigned him/her?• Who else was involved? • Who else can help prevent recurrence?

WHAT• What safety system failed?

(STAs, JSAs, training, hazard identification, enforcement, inadequate rules)

• What did the supervisor do to prevent theinjury?

• What type of training has the employee had?• What was the incident?• What was the injury?• What was he/she doing?• What had he/she been told to do?• What tools was he/she using?• What machine was involved?• What operation was he/she performing?• What instructions had he/she been given?• What specific precautions were necessary?• What specific precaution was he/she given?• What protective equipment should have

been used?• What protective equipment was he/she using?• What had other persons done that contributed

to the incident?• What problem or question did he/she encounter?• What did he/she or witnesses do when the incident

occurred?• What extenuating circumstances were

involved?• What will be done to prevent recurrence?• What safety rules were violated?• What new rules are needed?• What did he/she or witnesses see?

WHEN• When did the incident occur?• When did he/she start on that job?• When was he assigned on the job?• When were the hazards pointed out to him/her?• When did his/her supervisor last check on job

progress?• When did he/she first sense something was wrong?

WHY• Why did the safety system fail?• Why was he/she injured?• Why did the other person do what he did?• Why wasn't protective equipment used?• Why weren't specific instructions given him/her?• Why was he/she in the position he/she was?• Why was he/she using the tools or machine he/she

used?• Why didn't he/she check with his/her supervisor when

he/she noted things weren’t, as they should?• Why did he/she continue working under the

circumstances?• Why wasn’t supervisor there at the time?

WHERE• Where did the incident occur?• Where was the supervisor at the time?• Where were fellow workers at the time?• Where were other personnel who were involved at the

time?• Where were witnesses when incident occurred?

HOW• How did he/she get injured?• How could he/she have avoided it?• How could fellow workers have avoided it?• How could supervisor have prevented it?

Incident Reporting and Investigation This is a controlled document. No un-authorized modifications.Health, Safety, and Environmental


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9.0 INCIDENT INVESTIGATIONThe basic purpose of an incident investigation is to prevent a recurrence of the incident.

The objectives of an incident investigation are:

Determination of root causes of incidents Correction of unsafe conditions Elimination of unsafe acts Improvement of work capability Improvement of supervision

The investigation phase begins as soon as supervision is made aware of the incident. While treatment of injuries and immediate HSE concerns created by the incident are the initial top priority, supervision should be carefully observing the incident scene – planning for follow-up action and future reference.

Once the immediate needs caused by the incident have been satisfied, the incident investigation process begins to gather data relevant to the incident. Prompt incident investigation may reveal contributing factors to the incident that may not be present at a later date and time.

As soon as possible, taking into account any injuries or personal problems as a result of the incident, interviews with the personnel involved in, and witnesses to, the incident will be conducted.

The important considerations after an incident are:

Mitigate the impact to personnel involved in the incident. Mitigate the impact to the construction site and other personnel as a result of the

incident. Prevent reoccurrence of a similar incident.

Project/Site Management, including the site HSE Representative, will review the report(s) and distribute once the investigation is finalized and will meet the timing required by Dow.



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10.0 OWNER INVESTIGATION ATTENDEESThe following Owner representatives must be invited to attend the RCI:

Affected contractor employee Contractor company supervision including foreman, superintendent, and

safety contact Dow Construction Manager Dow Construction Safety Leader Dow Project Manager (for OSHA recordables only) Dow Program Construction Manager (for OSHA recordables only) Dow Program EH&S Leader (for OSHA recordables only)

11.0 CLASSIFYING AND RECORDING INCIDENTS

The HSE Representative will receive and review incident reports and perform the following for each contractor occupational injury and illness:

Call employees and/or supervisors (as appropriate) for additional information as needed.

Review potentially recordable cases and status changes.

Determine recordability of cases with a date of injury/diagnosis based on information available at that time in accordance with the requirements in 29 Code of Federal Regulations (CFR) 1904.

Communicate case status changes to management and also notify them of cases requiring reevaluation by the occupational healthcare provider.

Track receipt of incident reports.

Transmit a copy of incident reports according to the owner process.



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12.0 OTHER REPORTING REQUIREMENTS

Overview – Weekly Reports

Introduction This section describes the Gulfstream weekly reporting requirements.

Requirements Following is a list of the weekly reports in this section. The actual day of the week the report is submitted will be agreed on by Gulfstream EH&S and the contractor company.

Report Description

Medical summary report from on-site medic

This report should include a summary of all medical visits, the treatment given, and classification.

Construction site weekly work hours A summary report by company of hours worked for the previous week. This data is used to calculate safety statistics for the Gulfstream Program.This data includes sub contractor hours.

Construction site weekly HSE report A summary report by company of hours worked, incidents, medical visits, top hazards observed, etc.

Overview – Monthly Reports

Introduction This section describes the Gulfstream monthly reporting requirements.

Requirements Following is a list of the monthly reports in this section:

Report Description

Construction site monthly work hours

A summary report by company of hours worked for the previous month. This data is used to calculate safety statistics for the Gulfstream Program.This report is due by the end of the 2nd working day of the month.This report includes all sub contractors by company name.



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Construction site monthly drug testing report

A summary report by company of drug testing data for the previous month. Data required is: number of random tests completed, number of positive tests, total number of company employees on the job site for the month.

Construction site monthly HSE report

A summary report by company of hours worked, incidents, medical visits, top hazards observed, etc.

Construction site 6 month rolling HSE report

This report is generated at the beginning of each month for each project that includes HSE data from the previous 6 months.This report is intended to be used to look at trends.

Overview – Additional Reports

Introduction This section describes the Gulfstream additional reporting requirements. These may be set project by project

Requirements Following is a list of the reports in this section:

Report Description

Incident reports For incident reporting requirements, see the Gulfstream Incident Investigation Process described above.



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Overview – Reporting Procedure

Introduction This section describes the reporting procedure for submitting the various Gulfstream contractor reports.

Responsibility If a contractor company has completed a job and does not anticipate working on a Gulfstream construction site for an extended period of time, it will be their responsibility to notify Owner EH&S via e-mail that they will no longer be submitting the data in this policy.Upon their return to the site, the contractor company will resume submitting their reports as indicated in this policy.

Procedure Direct all Gulfstream reports or questions to the designated Dow HSE representative.Gulfstream Reports must be submitted by e-mail to [email protected]. Monthly work hour reports are due by the 2nd working day of the month.

Step Action

1 3 All monthly work hour reports are due the 2nd working day of each month. Other reports will be agreed on at the start of the project.

4 6 Submit forms to Owner EH&S by e-mailing them to Gulfstream EH&S Functional Mailbox, [email protected].

7 9 Work Hours and Random Drug Tests must be submitted on the form supplied by Dow.

10 11 12 Identify email in Subject Line: Example: Monthly Reports – Company Name – Month, Year

13 14 15 Include YTD Totals on forms.

16 17 18 Include company name on forms.



mailto:[email protected]

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13.0 REFERENCES

Document ID Document Title

Gulfstream Incident Master

Gulfstream Incident-Injury Report Form

Gulfstream Work Hours Drug Testing Form

Other Documents

29 CFR 1904 OSHA Recordkeeping



http://osha.gov/recordkeeping/index.html

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