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PERFORMANCE
REPORTING
AND
ACCIDENT
INVESTIGATION
HUMAN BEHAVIOR
SHIELDS = HSE
MANAGEMENT
SYSTEM
PERFORMANCE
RECORDABLE ACCIDENTS
RECORDABLE INJURY
An unplanned event that results in an injury to a person (cut, fracture, sprain, amputation), which is
the consequence of:
a work related activity
an exposure involving a single incident in the work environment
(deafness from explosion, one-time chemical exposure, back disorder from a slip / trip, fracture
caused by fall from height, animal bite, poor housekeeping resulting in a trip of a person)
OCCUPATIONAL ILLNESS is NOT SAFETY RECORDABLE
OCCUPATIONAL ILLNESS - any abnormal condition or disorder, other than one resulting from an
occupational injury, caused by exposure to environmental factors associated with employment. It
will generally result from prolonged or repeated exposure.
An Occupational Illness can be:
Back problems and lower limb disorders
Cancers and malignant blood diseases
Infectious/preventable diseases (malaria, food poisoning, infectious hepatitis, dysentery)
Noise induced hearing loss
Poisoning (systemic effects of toxic materials)
Skin diseases and disorders (contact dermatitis, allergic dermatitis, rash caused by primary
irritants, sensitizers or poisonous plants)
Physical disorders resulted from heat stress, exposure to low temperatures; effects of ionising
(alpha, beta and gamma rays, radium) and non-ionising (welding flash, ultraviolet rays, sunburn)
radiation).
CALCULATION OF SAFETY
INDICATORS
WORKED MANHOURS
Offshore units
No persons on board/day x No.
days worked x 12 hours/day
Onshore units
No persons present each day x No.
days worked x No. hours
worked/day
AVERAGE MANPOWER
No of persons present at work each
day in a month / no of days worked
in month
Fatalities
LTI
Work Restricted
Personal Injuries
Medical
treatments
First Aid
Employee slips on the
scaffold and..
suffers a scratch on his
finger
sprain his ankle while
attempting to regain his
balance
falls from scaffold and
suffer multiple fractures
falls from scaffold and
suffer fatal injuries to
head
Near Miss
Employee slips on the
scaffold but he regain
the balance
Safety and Hazard
Observation Cards
PERFORMANCE MEASURMENT
LTIFR =
Severity Rate
SR =
N . LWD 1, 000
Total Work ed _ Manhours
TRIFR =
PROACTIVE INDICATORS
HSE TRAINING HOURS
Include the safety & environmental training courses provided to Company and
Contractor personnel on Company facilities and on external facilities, agreed by the
Company.
HSE Training Hours have to be considered as Contact hours and it is calculated
by multiplying the number of attendees with the duration of the training session.
In the calculation of HSE Training hours shall not be included Safety Induction
Training such as offshore arrival, neither Emergency Drills.
PROACTIVE INDICATORS
HSE MEETINGS
Any specific HSE meeting held in work site, base camp, offices and naval assets
where HSE matters are predominately discussed. It does not include Project
Progress meeting (even if HSE related matters are discussed)
HSE INSPECTIONS
A planned tour of a workplace to examine the site facilities, equipment, tools and
the employees practices in using them. HSE Inspection may also includes the so
called Safety Walkthroughs
It is a generic term, used to identify all the situations, conditions observed and
reported by the personnel employed in a project or site. Observation reported are
always dealt with immediately after notification, solved by means of short-term
action and recorded
ACCIDENT INVESTIGATION
Accidents = Injuries
Why?
Because Injuries costs:
Insurance Premiums
Medical Expenses
Worker Compensation
Rest of work crew takes up the slack
Identify the sequence of events leading to accident and the causes of failures associated to
each step;
Find methods to prevent accidents from recurring;
Communicate within the company and/or other companies the problems encountered during
activity carried out;
Provide information on the status of strategies applied by the company to control the risks to
health and safety;
COMMUNICATE
EVALUATE
LOCATION
FOLLOW UP BY HSE
SUPERVISOR IMMEDIATE ACTION
INCIDENT NOTIFICATION
On site the first notification, imediatelly after occurrence,
shall be done verbally.
The notified person will evaluate the situation and take
appropriate action to protect personnel, the environment
and assets.
THE PROCESS
Worker / Employee
Incident
Near-Misses
Accidents /
High Potential Near Misses
Site Superintendent
Site Superintendent /
HSE Manager / Project Manager
RISK MATRIX
Purpose of investigation
Identify the immediate and underlying causes
Enable effective control measures to be developed.
Asses the potential consequence of all accidents / near miss establishing the urgency of response and level of
investigation required and prioritize corrective actions and implementation of control measures.
Level A
Level B
Company/Subcontractor Representative
Event Report
Level C
The investigation team shell be
defined jointly with Construction
Business Units managers and
Integrated Projects Senior Vice
President in consultation with
relevant Functions of Contractor
Corporate Management (QHSE,
Assets)
ACCIDENT INVESTIGATION
1. WHO
2. WHAT
3. WHEN
4. WHERE
5. HOW
6. WHY
1. PEOPLE
2. PARTS
and
3. POSITIONS
Direct causes
Underlying causes
Unsafe acts
Unsafe conditions
Root causes
Personal factors
Job Factors
Critical factors are those events or conditions that if eliminated, either would have prevented the
incident or reduced its intensity.
ROOT CAUSE
The root cause of the accident is the basic underlying reason, not always apparent, that
caused the accident.
Example: The root cause of the accident was that the person who spilled the coffee did not
clean it up or establish a warning method to alert others of a hazard.
INCIDENT MAPPING
A critical factors chart in the form of a timeline is developed using building blocks of incident
events and conditions. This is known as data mapping. Chart helps the investigators to
chronologically describe the events leading to the accident.
Events mapping
Underlying cause 1
Underlying cause 2
Underlying cause
Underlying cause
Underlying cause
Root causes
Root causes
Underlying cause
Underlying cause 3
Root causes
EXAMPLE
Example of Facts Gathering
On July 29, 1999, on or about 10:45 am, Joe Employee was stacking concrete blocks and walked
into a piece of steel re-enforcing bar that was protruding out of the end of the pipe storage
shelving unit located inside the Project Materials compound, striking him in the face. A 1 cut was
received across the middle of Mr. Employees forehead. He proceeded directly to the dispensary,
where he received 4 sutures to close the laceration, then was released at 11:41am in a full duty
status. He went to lunch, then informed his immediate supervisor of the incident upon returning
to work at 12:30.
Direct cause
The accident was caused by Joe not paying attention to his surroundings
and striking his head on the rebar.
Root Cause #1: Somebody didnt properly store the rebar and left it in a
haphazard state that was obviously unsafe.
Root Cause #2: The supervisor has not been taking responsibility for his
work area by monitoring for unsafe conditions.
SUBSTANDARD ACTS/PRACTICES
SUBSTANDARD CONDITIONS
Poor housekeeping
Failure to warn
Failure to secure
Noise or temperature
Radiation exposure
Inadequate ventilation
Environmental conditions
ROOT CAUSES
Personal factors
Ergonomic
Physical capability
Mental/ psychological capability
Physical stress
Workload stress
Lack of design
Job factors
Management/ Supervision / Employee leadership
Standards, policies, procedures (PSP)
Confusion requests
Communication
Training
Engineering , design
Purchasing, material handling and material control
Contractor selection
Maintenance
Tools and equipment
Excessive wear and tear
Abuse or misuse
But
Training
Procedures
- specify the exact corrective action to be implemented: Who will do what when?
Measurable - fix exact date for applying the corrective actions and check if they are really working : When is done
and if is working?
Accountable - who is the responsible person for implementing the corrective actions and clearly define the due date.
Reasonable - what are the costs for implementing the specific corrective actions: is the corrective action practical?
Timely
Effective
- the corrective actions must prevent or significantly reduce the odds of the accident recurring.
Reviewed
are the corrective actions soon enough established to produce consequences or to reduce risks while
corrective actions are being implemented?
- the corrective actions must be reviewed after an established period of time in order to see if they have
produced the expected effect or need improvement.
REPORTING
The following principles for the preparation of an Incident Investigation Report shall be adhered to:
9
Interpretations of findings should be based only on the facts as identified in the investigation;
Where events and conditions are listed in the report but are not essential pre-conditions for occurrence of the
incident these should be clearly identified;
An assessment of underlying root causes should be made, based on an analysis of the evidence;
Where events or conditions are listed, that are not critical for the incident to have occurred, this should be
clearly indicated;
The report should be readable as a stand-alone document. References to other documents not in the public
domain, i.e. not readily open to inspection by others, should be avoided;
An audit trail of the documents relevant to the incident and the report should be established;
The team leader should ensure that all documentation collected during the investigation and preparation of the
report is properly filed;
Site identification
Type of injury
Accident analysis
Accident Investigation
Corrective actions